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Computerized system and methods for generating and processing integrated transactions for healthcare services

  • US 20060259324A1
  • Filed: 01/06/2006
  • Published: 11/16/2006
  • Est. Priority Date: 01/06/2005
  • Status: Active Grant
First Claim
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1. A method in a computing environment for adjudicating and reimbursing a care provider for services provided for a clinical event, comprising:

  • receiving a transaction including a number of clinical data elements for the clinical event;

    accessing a data store including payer information;

    determining whether the transaction is eligible for reimbursement by at least one payer;

    accessing a first knowledge base comprising evidence-based options for providing medically appropriate care;

    selectively performing analysis of the clinical data elements of the transaction against at least one option from the first knowledge base to determine if the care provided is medically appropriate;

    accessing a second knowledge base comprising at least one criterion for assessing quality of care;

    selectively performing analysis of the clinical data elements of the transaction against the at least one criterion to determine the quality of care; and

    determining a level of reimbursement based on the medical appropriateness and quality of the care provided and authorizing reimbursement of the care provider from at least one payer.

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