Method and apparatus for a generic mechanism for adjudication of claims in a claims processing system
First Claim
1. A method in a data processing system for adjudication of claims in a claims processing system, the method comprising:
- receiving at least one claim submission from a host system;
converting the at least one claim submission to at least one generic message;
validating the at least one generic message;
converting the at least one valid generic message to at least one formatted message, wherein the at least one formatted message is formatted using a format designated by a clearing house application; and
sending at least one formatted message to the clearing house application for adjudication.
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Abstract
A method and system for a generic mechanism for adjudication of claims in a claims processing system. The generic mechanism comprises a Web services module, a Web portal, a batch loader, a claim database, and an interface engine. The Web services module, the Web portal, and the batch loader are used by medical providers to submit claims. Upon submission, claim information is converted to generic messages and sent to the interface engine. The interface engine validates the generic messages using a claim schema, prior to converting them to an internal message format, and sending them to a clearing house application. When messages are adjudicated by the clearing house application, they are returned to the interface engine, where the return messages are converted back to generic messages and validated against a return message schema. Valid messages along with any error are returned to the medical providers and submitted for payment approval.
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Citations
26 Claims
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1. A method in a data processing system for adjudication of claims in a claims processing system, the method comprising:
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receiving at least one claim submission from a host system;
converting the at least one claim submission to at least one generic message;
validating the at least one generic message;
converting the at least one valid generic message to at least one formatted message, wherein the at least one formatted message is formatted using a format designated by a clearing house application; and
sending at least one formatted message to the clearing house application for adjudication. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15)
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16. A method for adjudication of claims in a claims processing system, the method comprising:
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receiving a request for adjudication of claims from a host system;
converting the request to a generic request, wherein the generic request is formatted in a first markup language;
validating the generic request using a first schema;
converting the validated generic request to a proprietary request; and
sending the proprietary request and a set of rules to a rule engine for adjudication. - View Dependent Claims (17, 18)
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19. A data processing system for adjudication of claims in a claims processing system, the data processing system comprising:
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receiving means for receiving at least one claim submission from a host system;
first converting means for converting the at least one claim submission to at least one generic message;
first validating means for validating the at least one generic message;
second converting means for converting the at least one valid generic message to at least one formatted message, wherein the at least one formatted message is formatted using a format designated by a clearing house application; and
first sending means for sending at least one formatted message to the clearing house application for adjudication. - View Dependent Claims (20, 21, 22)
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23. A computer program product in a computer readable medium for adjudication of claims in a claims processing system, the computer program product comprising:
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first instructions for receiving at least one claim submission from a host system;
second instructions for converting the at least one claim submission to at least one generic message;
third instructions for validating the at least one generic message;
fourth instructions for converting the at least one valid generic message to at least one formatted message, wherein the at least one formatted message is formatted using a format designated by a clearing house application; and
fifth instructions for sending at least one formatted message to the clearing house application for adjudication. - View Dependent Claims (24, 25, 26)
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Specification