Healthcare Claims Processing Mechanism for a Transaction System

• US 20060020495A1
• Filed: 07/20/2004
• Published: 01/26/2006
• Est. Priority Date: 07/20/2004
• Status: Abandoned Application

• Current Assignee: Vested Health LLC (The Health Plan of West Virginia, Inc.)
• Original Assignee: Vested Health LLC (The Health Plan of West Virginia, Inc.)
• Inventors: Jenkins, Stephen Reed, Platz, Stephen James, Bornacorso, John I, Baker, Michael Stephen
• Application Number:
  US10/710,552
• Publication Number:
  US 20060020495A1
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A structured healthcare claims processing mechanism for use with funded accounts (e.g., healthcare reimbursement arrangements, healthcare savings accounts and flexible spending accounts) is disclosed, including a claims processing mechanism, a registration mechanism, a claim submission mechanism, a payment mechanism and an insurance submission mechanism.

Claims

1. A healthcare claims management and payment transaction system comprising:

a registration mechanism constructed and arranged to generate and transmit a message representing registration information to the system;

a claim submission mechanism constructed and arranged to generate and transmit a message representing claim information to the system; and

a claim processing mechanism constructed and arranged,

to receive a message representing claim information generated and transmitted by the claim submission mechanism9

to receive a message representing registration information generated and transmitted by the registration mechanism, and

to generate and transmit a message representing payment authorization to a payment mechanism, the payment authorization being based at least in part on the registration information and the claim information.

2. The system of claim 1, wherein the registration mechanism is further constructed and arranged to receive a message representing registration information from one or more user.

3. The system of claim 1, wherein the claim submission mechanism is further constructed and arranged to receive a message representing claim information from one or more users.

4. The system of claim 1, wherein the claim processing mechanism is further constructed and arranged to generate and transmit a message representing claim information and payment authorization to the registration mechanism.

5. The system of claim 4, wherein the registration mechanism is further constructed and arranged to generate and transmit a message containing some or all of the claim information, registration information and/or payment authorization to one or more users

6. The system of claim 1, wherein the payment authorization is based in part on the claim information as compared to one or more templates and/or rule sets.

7. The system of any of claims 1-6, wherein the payment mechanism is constructed and arranged to receive a message containing payment authorization from the claim processing mechanism, and to generate and transmit a funds transfer message based upon such authorization to cause funds to be transferred from a funded account to a provider account.

8. The system of claim 1, wherein the claim processing mechanism is further constructed and arranged to generate and transmit a message representing some or all of the claim information, the registration information and/or the payment authorization to an insurance submission mechanism.

9. The system of claim 8, wherein

the insurance submission mechanism is further constructed and arranged to generate and transmit a message representing an insurance claim action;

the claim processing mechanism is further constructed and arranged to receive a message representing insurance claim action from the insurance submission mechanism, and to generate and transmit a second funds transfer message representing payment authorization to the payment mechanism, the payment authorization based at least in part on the insurance claim action and the registration information.

10. A method of managing and paying healthcare claims, the method comprising:

by a registration mechanism, generating a message representing registration information to the system;

by a claim submission mechanism, generating a message representing a healthcare claim to the system; and

by a claim processing mechanism, obtaining a message representing registration information generated by the registration mechanism,

obtaining a message representing a healthcare claim generated by the claim submission mechanism, and

generating and transmitting a message representing payment authorization to a payment mechanism, the payment authorization being based at least in part on the claim information and the registration information.

11. The method of claim 10 further comprising the claim submission mechanism receiving a message representing a healthcare claim from one or more users

12. The method of claim 10, further comprising the claim processing mechanism generating and transmitting a message representing the healthcare claim and the payment authorization to the registration mechanism.

13. The method of claim 10, wherein the payment authorization is based in part on the claim information as compared to one or more templates and/or rule sets.

14. The method of claim 10, further comprising the registration mechanism generating and transmitting a message containing some or all of the claim information, registration information and/or payment authorization to one or more users.

15. The method of any of claims 10-14, further comprising the payment mechanism receiving a message containing payment authorization from the claim processing mechanism, and generating and transmitting a message to cause funds to be transferred from a funded account to a provider account.

16. The method of claim 10, further comprising the claim processing mechanism generating and transmitting a message representing some or all of the claim information the registration information and/or the payment authorization to an insurance submission mechanism.

17. A memory for storing data for access by an application program being executed on a data processing system, comprising:

a data structure stored in the memory, said data structure including

information relating to one or more users issued by a registration server,

claim information relating to services performed by or on behalf of any of said one or more users, said claim information being issued by a claim submission server, and

payment authorization information issued by the data processing system of the present invention, said payment authorization being based at least on the registration information, the claim information and one or more templates and/or rule sets.

18. A system for managing, processing and paying healthcare claims, the system comprising:

a claims submission mechanism having means for issuing electronic signals representing claim information to the system;

a registration mechanism having means for issuing electronic signals representing registration information to the system; and

a claims processing mechanism comprising means for obtaining electronic signals representing claim information issued by the claims submission mechanism,

means for obtaining electronic signals representing registration information issued by the registration mechanism, and

means for issuing electronic signals representing payment authorization, the payment authorization being based at least on the claim information and the registration information.

19. The system of claim 18, wherein the registration mechanism further comprises means for obtaining an electronic signal representing registration information from one or more users, and the claim submission mechanism further comprises means for obtaining an electronic signal representing claim information from one or more users.

20. The system of claim 18, wherein the payment authorization is based further on the claim information as compared to one or more templates and/or rule sets.

21. The system in claim 18, further comprising a payment mechanism comprising means for obtaining electronic signals representing payment authorization from the claim processing mechanism, and means for issuing electronic signals to cause funds to be transferred from a funded account to a provider account.

22. An apparatus for managing, processing and paying healthcare claims, the apparatus comprising:

a mechanism constructed and adapted to receive a message representing registration information;

a mechanism constructed and adapted to receive a message representing healthcare claim information; and

a mechanism constructed and adapted to generate and transmit a message representing payment authorization.

23. The apparatus of claim 22, wherein the mechanism is further constructed and adapted to generate and transmit a message containing claim information and action to one or more users.

24. The apparatus of claim 22, wherein the payment authorization is based in part on the claim information as compared to one or more templates and/or rule sets.

25. The apparatus of any of claims 22-24, wherein the mechanism is further constructed and adapted to generate and transmit a message representing some claim information and registration information, to an insurance submission mechanism.

26. An apparatus for managing, processing and paying healthcare claims, the apparatus comprising:

means for receiving electronic signals representing a healthcare claim;

means for receiving electronic signals representing registration information;

means for generating a message based on the healthcare claim and the registration information, the message specifying payment authorization for a sum certain; and

means for transmitting electronic signals representing the payment authorization message to a payment mechanism.

27. The apparatus of claim 26, further comprising means for transmitting electronic signals representing claim information and payment authorization to a registration mechanism.

28. The apparatus of claim 26, wherein the payment authorization is based further on the claim information as compared to one or more templates and/or rule sets.

29. The apparatus of any of claims 26-28, further comprising means for transmitting electronic signals representing some claim information, registration information and payment authorization to an insurance submission mechanism.

30. Computer readable media tangibly embodying a program of instructions executable by a computer to perform a method of managing, processing and paying healthcare claims in an electronic transaction system, the method comprising, by a claims processing mechanism:

receiving electronic signals representing claim information from a claims submission mechanism;

receiving electronic signals representing registration information from a registration mechanism;

creating a message based on claim information and registration information, the message specifying claim payment authorization; and

sending electronic signals representing the message to a payment mechanism requesting claim payment.

31. At least one computer programmed to execute a process for managing, processing and paying claims, the process comprising:

receiving electronic signals representing a claim;

receiving electronic signals representing registration information;

creating a payment authorization message specifying payment of the claim; and

causing electronic signals representing the payment authorization message to be sent to a payment mechanism.

32. The computer of claim 31, wherein the payment authorization is based in part on the claim information as compared to one or more templates and/or rule sets.

33. The computer of claim 32, wherein the process further comprises

creating a message representing some claim information, registration information and payment authorization;

and

causing electronic signals representing the message to be sent to an insurance submission mechanism.