System, method, and computer program product for processing a claim

• US 20060116913A1
• Filed: 11/29/2005
• Published: 06/01/2006
• Est. Priority Date: 11/30/2004
• Status: Abandoned Application

• Current Assignee: Lodi Systems LLC
• Original Assignee: Lodi Systems LLC
• Inventors: Wadia, Zubin R., Hansan, Kevin C.
• Application Number:
  US11/289,941
• Publication Number:
  US 20060116913A1
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A system, method, and computer program product for processing a claim are described. The system may include at least one intake site, a plurality of reviewers, one or more service providers, a bill payer and a claim process engine that may all be coupled to a network. In accordance with one embodiment, information about a claim brought by a claimant may be received from an intake site. A record for the claim may be created in a database that includes the information about the claim received from the intake site. Information from the record may be presented to one or more of the reviewers for determining whether to approve the claim. Information relating to an action taken by each reviewer regarding the claim may be received and the record in the database may be updated to include the information relating to the action. The intake site and/or the reviewer(s) may be provided with status information about a current status of the claim. The status information may be updated at least until the claim has been approved by the reviewer(s).

Claims

1. A method for processing a claim, comprising:

receiving from an intake site information about a claim brought by a claimant;

creating a record for the claim in a database that includes the information about the claim received from the intake site;

presenting information from the record to a reviewer for determining whether to approve the claim;

receiving information relating to an action taken by the/each reviewer regarding the claim;

updating the record in the database to include the information relating to the action; and

providing at least one of the intake site and the reviewer with status information about a current status of the claim, the status information being updated at least until the claim has been approved by the reviewer.

2. The method of claim 1, wherein the action comprises sending the claim to a hold queue.

3. The method of claim 2, further comprising re-presenting information from record to the review after a predetermined amount of time after performance of the action and requiring the review to perform a subsequent action for determining whether to approve the claim.

4. The method of claim 1, wherein information about previously taken actions relating to the claim is presented to at least one of the intake site and the reviewer.

5. The method of claim 4, wherein the information about previously taken actions is presented as an audit trail in a graphical user interface.

6. The method of claim 1, wherein the information received from the intake site and the reviewer is received via a network.

7. The method of claim 6, wherein the intake site and the reviewer are presented with a graphical user interface for inputting information relating to the claim.

8. The method of claim 1, further comprising generating an approval form after receipt of the approval from the reviewer.

9. The method of claim 1, further comprising:

providing a service provider access to information from the record associated with the claim for obtaining of an assessment of the claim from the service provider to identify a service for resolving the claim;

receiving information relating to the assessment from the service provider; and

updating the record in the database to include the information relating to the assessment.

10. The method of claim 9, further comprising presenting information from the record to the reviewer for determining whether to authorize the one or more services identified in the assessment within a predefined amount of time.

11. The method of claim 10, further comprising receiving an authorization from the reviewer for performing the one or more services;

and sending a notification to the service provider indicating approval by the reviewer for performing the one or more services.

12. The method of claim 11, further comprising receiving information indicating the performance of at least one of the approved services from the service provider after the service provider has performed the at least one of the approved services;

and updating the record in the database to include the information indicating the performance of the at least one of the approved services.

13. The method of claim 12, further comprising transmitting a notification to at least one of intake site, the reviewer and the service provider that indicates the performance of the at least one of the approved services.

14. The method of claim 1, wherein the action taken by the reviewer comprises recommending that a second reviewer review at least a portion of the information of the record.

15. The method of claim 1, further comprising presenting to a bill payer a graphical representation of a bill received for a service performed on the claimant;

receiving from the bill payer input for generating a payment for the bill, the input being obtained from the graphical representation of the bill and the information from the record; and

updating the record to include the input for generating the payment for the bill.

16. The method of claim 15, further comprising presenting information from the record to the reviewer for determining whether to authorize the payment of the bill;

wherein the action performed by the reviewer relates to the payment of the bill.

17. The method of claim 16, further comprising receiving an authorization for payment of the bill from the reviewer;

and providing at least one of the intake site, the service provider, the bill payer and the reviewer with a notification indicating that the authorization for payment of the bill.

18. The method of claim 15, wherein the graphical representation of the bill comprises a captured digital image.

19. A computer program product for processing a claim, comprising:

computer code for receiving from an intake site information about a claim brought by a claimant;

computer code for creating a record for the claim in a database that includes the information about the claim received from the intake site;

computer code for presenting information from the record to a reviewer for determining whether to approve the claim;

computer code for receiving information relating to an action taken by the reviewer regarding the claim;

computer code for updating the record in the database to include the information relating to the action; and

computer code for providing at least one of the intake site and the reviewer with status information about a current status of the claim, the status information being updated at least until the claim has been approved by the reviewer.

20. A system for processing a claim, comprising:

a network;

an intake site, a plurality of reviewers, a service provider and a bill payer coupled to the network;

a claim process engine coupled to the network and having;

logic for receiving from the intake site information about a claim brought by a claimant;

logic for creating a record for the claim in a database;

logic presenting information from the record to at least one of the reviewers for determining whether to approve the claim;

logic for presenting information to the service provider for presenting information about claim for assisting the service provider in assessing the claim and recommending one or more services for resolving the claim;

logic for presenting bill payment information to the bill payer;

logic for receiving information relating to actions taken by intake site, the reviewers, the service provider and the bill payer regarding the claim;

logic for affording a hold queue wherein actions sending the claim to the hold queue requires a subsequent action to be taken after a predetermined amount of time;

logic for updating the record in the database to include the information relating to the action; and

logic for providing at least one of the intake site, one or more of the reviewers and the bill payer with status information about a current status of the claim.