Method of increasing efficiency in a medical claim transaction, and computer program capable of executing same
8 Assignments
0 Petitions
Accused Products
Abstract
A method of adjudicating a medical claim includes providing a requirements for a first claim and a second claim, receiving a medical claim for a medical procedure, setting a first score for the first claim and a second score for the second claim to an initial value, comparing components of the medical claim to the requirements of the first and second claims, changing the first and second scores for each one of the components that match one of the requirements and for each one of the requirements that is missing from the components, and selecting the first or second claim based upon predetermined criteria applied to their respective scores to determine either a monetary value of the medical procedure for a medical service provider associated with the medical procedure or a monetary value of medical coverage for a patient associated with the medical procedure.
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Citations
55 Claims
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1-27. -27. (canceled)
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28. A method of processing a medical claim in a medical claim transaction initiated by a submission of the medical claim via an electronic medium to a medical plan provider on behalf of a patient making a visit to a medical service provider, the method comprising:
prior to a termination of the patient'"'"'s visit to the medical service provider;
performing an analysis routine comprising;
identifying a most-recently-received medical claim for the patient received from the medical service provider, where the most-recently-received medical claim can be the medical claim or a different medical claim;
analyzing the most-recently-received medical claim in order to determine whether the most-recently-received medical claim is in condition for approval;
if the most-recently-received medical claim is in condition for approval;
approving the most-recently-received medical claim;
informing the medical service provider via the electronic medium that the most-recently-received medical claim has been approved; and
terminating the medical claim transaction; and
if the most-recently-received medical claim is not in condition for approval;
rejecting the most-recently-received medical claim;
identifying at least one reason the most-recently-received medical claim was rejected; and
transmitting a message containing information regarding the rejection of the most-recently-received medical claim and the at least one reason for rejection to the medical service provider via the electronic medium. - View Dependent Claims (29, 30, 31, 32, 33, 34, 35, 36, 37)
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38. An interactive claims processing method comprising:
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receiving a medical claim via an electronic medium on behalf of a patient of a medical service provider while the patient is in an office of the medical service provider, thereby initiating a medical claim transaction; and
while the patient remains in the office of the medical service provider;
analyzing the medical claim in order to determine whether the medical claim is in condition for approval;
if the medical claim is in condition for approval;
approving the medical claim; and
informing the medical service provider via the electronic medium that the medical claim has been approved;
if the medical claim is not in condition for approval;
identifying an alteration that would place the medical claim in condition for approval; and
transmitting a message containing information regarding a rejection of the medical claim and the alteration to the medical service provider via the electronic medium. - View Dependent Claims (39, 40, 41, 42, 43, 44, 45)
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46. An interactive claims processing method comprising:
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receiving in real time a medical claim via an electronic medium on behalf of a patient of a medical service provider;
performing an analysis routine comprising;
analyzing the medical claim in real time in order to determine whether the medical claim is in condition for approval;
if the medical claim is in condition for approval;
approving the medical claim in real time;
informing the medical service provider in real time via the electronic medium that the medical claim has been approved; and
terminating the interactive claims processing method; and
if the medical claim is not in condition for approval;
rejecting the medical claim in real time;
identifying in real time at least one reason the medical claim was rejected; and
transmitting in real time a message containing information regarding the rejection of the medical claim and the at least one reason for rejection to the medical service provider via the electronic medium in order to enable the creation of an altered medical claim on behalf of the patient comprising the medical claim as modified according to the information;
if the interactive claims processing method has not been terminated, performing a determination routine comprising;
determining in real time whether the altered medical claim has been received;
if the altered medical claim has been received;
performing the analysis routine on the altered medical claim; and
if the altered medical claim has not been received;
terminating the interactive claims processing method; and
if the interactive claims processing method has not been terminated, repeating the determination routine.
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47. An interactive claims processing method comprising:
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receiving a request for pre-approval of a medical claim via an electronic medium on behalf of a patient of a medical service provider while the patient is in an office of the medical service provider; and
while the patient remains in the office of the medical service provider, performing a pre-approval process comprising;
receiving the request for pre-approval via the electronic medium;
performing an analysis routine comprising;
analyzing the request for pre-approval in order to determine whether the request for pre-approval is in condition for approval;
if the request for pre-approval is in condition for approval;
approving the request for pre-approval;
informing the medical service provider via the electronic medium that the request for pre-approval has been approved; and
terminating the pre-approval process and waiting to receive and approve the medical claim associated with the request for pre-approval; and
if the request for pre-approval is not in condition for approval;
rejecting the request for pre-approval;
identifying at least one reason the request for pre-approval was rejected; and
transmitting a message containing information regarding the rejection of the request for pre-approval and the at least one reason for rejection to the medical service provider via the electronic medium in order to enable the creation of an altered request for pre-approval on behalf of the patient comprising the request for pre-approval as modified according to the information;
if the interactive claims processing method has not been terminated, performing a determination routine comprising;
determining whether the altered request for pre-approval has been received;
if the altered request for pre-approval has been received;
performing the analysis routine on the altered request for pre-approval; and
if the altered medical claim has not been received;
terminating the pre-approval process;
if the pre-approval process has not been terminated, repeating the determination routine;
receiving and approving the medical claim associated with the request for pre-approval;
informing the medical service provider via the electronic medium that the medical claim associated with the request for pre-approval has been approved; and
informing the medical service provider of the monetary values of the medical procedure to the medical service provider and to the patient. - View Dependent Claims (48, 49, 50, 51, 52, 53, 54, 55)
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Specification