System and method for operating modules of a claims adjudication engine

• US 20060149784A1
• Filed: 01/03/2005
• Published: 07/06/2006
• Est. Priority Date: 01/03/2005
• Status: Abandoned Application

• Current Assignee: Emergis Incorporated (Telus Corporation)
• Original Assignee: Emergis Incorporated (Telus Corporation)
• Inventors: Tholl, Rob, Russell, Clayton
• Application Number:
  US11/025,912
• Publication Number:
  US 20060149784A1
• Time in Patent Office: Days
• US Class Current: 1/1
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A system and method for configuring an adjudication system to adjudicate a claim transaction. The system and method comprise: receiving the claim transaction containing line items describing an insured service for a recipient to be financed by a payer for the insured service; providing an adjudication engine for coordinating the adjudication processing of the received claim transaction; representing the claim transaction as a plurality of business objects coupled to a database such that the business objects are selected from a set of available business objects, the business objects coupled to the adjudication engine and configured for containing data instances of the claim transaction; and selecting a plurality of adjudication modules for coupling to the plurality of business objects, the plurality of adjudication modules selected from a set of available adjudication modules, the selected adjudication modules configured for providing business logic applied to the business objects during the adjudication processing to manipulate the data instances of the business objects; wherein the configured adjudication system adjudicates the data instances of the business objects according to the business logic of the selected adjudication modules for determining an adjudication status of the claim transaction.

Claims

1. A method for configuring an adjudication system to adjudicate a claim transaction, the method comprising the steps of:

receiving the claim transaction containing at least one line item describing an insured service for a recipient to be financed by a payer for the insured service;

providing an adjudication engine for coordinating the adjudication processing of the received claim transaction;

representing the claim transaction as a plurality of data containers coupled to a database such that the data containers are selected from a set of available data containers, the data containers coupled to the adjudication engine and configured for containing data instances of the claim transaction; and

selecting a plurality of adjudication modules for coupling to the plurality of data containers, the plurality of adjudication modules selected from a set of available adjudication modules, the selected adjudication modules configured for providing business logic for application to the data containers during the adjudication processing to manipulate the data instances of the data containers;

wherein the configured adjudication system adjudicates the data instances of the data containers according to the business logic of the selected adjudication modules for determining an adjudication status of the claim transaction.

2. The method according to claim 1 further comprising the step of selecting the data containers from a set of available data containers.

3. The method according to claim 2, wherein the selection of the data containers is coordinated by the modules.

4. The method according to claim 2, wherein the data containers are represented as business objects associated with the database.

5. The method according to claim 4, wherein the business objects are selected from the group comprising:

claim;

claim item;

claim experience;

fiscal experience;

drug experience;

plan;

benefit;

provider; and

recipient.

6. The method according to claim 5, wherein the experience business objects are configured to contain historical information associated with the claim transaction.

7. The method according to claim 4 further comprising the step of the business objects collecting plan information from a hierarchy including inheritance characteristics of the business objects, the plan information related to the insured service associated with the claim transaction.

8. The method according to claim 4 further comprising the step of coupling the business objects to at least one hierarchy including inheritance characteristics of the business objects, the at least one hierarchy for describing a plan related to the insured service.

9. The method according to claim 8, wherein the at least one hierarchy provides for an override of attributes of the business objects.

10. The method according to claim 8 further comprising the step of selecting the hierarchies from the group comprising:

carrier;

benefit providing the benefits associated with the insured service; and

provider providing the insured services.

11. The method according to claim 4 further comprising the step of receiving a plurality of claim transactions for representing as the plurality of data containers, the plurality of claim transactions processed by the adjudication engine in parallel.

12. The method according to claim 4 further comprising the step of reusing selected data containers for a subsequent claim transaction processed after the claim transaction.

13. The method according to claim 1 further comprising the step of selecting the adjudication engine from a set of available adjudication engines based on at least one engine selection criterion, the at least one engine criterion associated with claim characteristics of the received claim transaction.

14. The method according to claim 13, wherein the adjudication engine contains definitions of the modules and the business objects to be applied based on the characteristics of the received claim transaction.

15. The method according to claim 13 further comprising the step of the adjudication engine coordinating the selection of the modules.

16. The method according to claim 15 further comprising the step of the adjudication engine coordinating the application of the business logic of the modules to the data instances of the data containers.

17. The method according to claim 13, wherein the adjudication engine is determined based on a line of business selected from the group comprising:

medical;

dental;

vision;

flexible benefits; and

drug.

18. The method according to claim 17, wherein the claim transaction contains line items pertaining to at least two lines of business.

19. The method according to claim 1 further comprising the step of the modules applying the business logic to the data instances of the data containers in order to determine the state of the data containers.

20. The method according to claim 3, wherein the modules instantiate the data containers according to a claim data container representing the characteristics of the claim transaction.

21. A system for configuring an adjudication system to adjudicate a claim transaction, the system comprising:

an adjudication system for receiving the claim transaction containing at least one line item describing an insured service for a recipient to be financed by a payer for the insured service;

an adjudication engine of the adjudication system for coordinating the adjudication processing of the received claim transaction;

a plurality of data containers coupled to a database for representing the claim transaction such that the data containers are selectable from a set of available data containers, the data containers coupled to the adjudication engine and configured for containing data instances of the claim transaction; and

a plurality of adjudication modules for coupling to the plurality of data containers, the plurality of adjudication modules selectable from a set of available adjudication modules, the adjudication modules configured for providing business logic for application to the data containers during the adjudication processing to manipulate the data instances of the data containers;

wherein the configured adjudication system adjudicates the data instances of the data containers according to the business logic of the selected adjudication modules for determining an adjudication status of the claim transaction.

22. The system according to claim 21, wherein the data containers are selectable from a set of available data containers.

23. The system according to claim 22, wherein the selection of the data containers is coordinated by the modules.

24. The system according to claim 22, wherein the data containers are represented as business objects associated with the database.

25. The system according to claim 24, wherein the business objects are selected from the group comprising:

claim;

claim item;

claim experience;

fiscal experience;

drug experience;

plan;

benefit;

provider; and

recipient.

26. The system according to claim 25, wherein the experience business objects are configured to contain historical information associated with the claim transaction.

27. The system according to claim 24, wherein the business objects are configured to collect plan information from a hierarchy including inheritance characteristics of the business objects, the plan information related to the insured service associated with the claim transaction.

28. The system according to claim 24 further comprising at least one hierarchy including inheritance characteristics of the business objects, the at least one hierarchy for describing a plan related to the insured service, the business objects coupled to the hierarchy.

29. The system according to claim 28, wherein the at least one hierarchy provides for an override of attributes of the business objects.

30. The system according to claim 28, wherein the hierarchies are selected from the group comprising:

carrier;

benefit providing the benefits associated with the insured service; and

provider providing the insured services.

31. The system according to claim 24, wherein the adjudication system is configured to receive a plurality of claim transactions are for representing as the plurality of data containers, the plurality of claim transactions processed by the adjudication engine in parallel.

32. The system according to claim 24, wherein the selected data containers are reusable for a subsequent claim transaction processed after the claim transaction.

33. The system according to claim 21 further comprising the adjudication system configured for selection of the adjudication engine from a set of available adjudication engines based on at least one engine selection criterion, the at least one engine criterion associated with claim characteristics of the received claim transaction.

34. The system according to claim 33, wherein the adjudication engine contains definitions of the modules and the business objects to be applied based on the characteristics of the received claim transaction.

35. The system according to claim 33, wherein the adjudication engine is configured to coordinate the selection of the modules.

36. The system according to claim 35, wherein the adjudication engine is configured to coordinate the application of the business logic of the modules to the data instances of the data containers.

37. The system according to claim 33, wherein the adjudication engine is determined based on a line of business selected from the group comprising:

medical;

dental;

vision;

flexible benefits; and

drug.

38. The system according to claim 37, wherein the claim transaction contains line items pertaining to at least two lines of business.

39. The system according to claim 21, wherein the modules are configured to apply the business logic to the data instances of the data containers in order to determine the state of the data containers.

40. The system according to claim 23, wherein the modules instantiate the data containers according to a claim data container representing the characteristics of the claim transaction.

41. A computer program product for configuring an adjudication system to adjudicate a claim transaction, the computer program product comprising:

a computer readable medium;

an adjudication system module stored on the computer readable medium for receiving the claim transaction containing at least one line item describing an insured service for a recipient to be financed by a payer for the insured service;

an adjudication engine module coupled to the adjudication system module for coordinating the adjudication processing of the received claim transaction;

a data container module coupled to the adjudication system module for providing a plurality of data containers coupled to a database for representing the claim transaction such that the data containers are selectable from a set of available data containers, the data containers coupled to the adjudication engine module and configured for containing data instances of the claim transaction; and

a plurality of adjudication modules for coupling to the plurality of data containers, the plurality of adjudication modules selectable from a set of available adjudication modules, the adjudication modules configured for providing business logic for application to the data containers during the adjudication processing to manipulate the data instances of the data containers;

wherein the configured adjudication system module adjudicates the data instances of the data containers according to the business logic of the selected adjudication modules for determining an adjudication status of the claim transaction.