System and method for managing the exchange of information between healthcare systems

• US 20070033066A1
• Filed: 08/04/2005
• Published: 02/08/2007
• Est. Priority Date: 08/04/2005
• Status: Active Grant

• Current Assignee: IDX Investment Corporation (General Electric Company)
• Original Assignee: IDX Investment Corporation (General Electric Company)
• Inventors: Harold, Monique, Khoury, Esther, Ammer, Mary, Belcher, Deborah
• Granted Patent: US 7,778,844 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: G16H 70/60 relating to pathologies

Abstract

An improved system for managing the exchange of information between healthcare systems. The system automatedly processes a healthcare data inquiry to produce a response readable by a requestor. This response may include content data, such as claims attachment data requested in a healthcare claims attachment inquiry. The content data may reside on data stores which the system must access in order to retrieve the necessary content data. The system may use criteria for automatedly interpreting the healthcare data inquiry.

Claims

1. A system for handling one or more healthcare data inquiry requiring content data, the system comprising:

(a) a processing module for receiving one or more healthcare data inquiries from a requestor in a first standard healthcare data format, said one or more healthcare data inquiries including at least one request for one or more desired content data;

(b) a worklist module in communication with said processing module, said worklist module for storing one or more work items; and

(c) a response module in communication with said processing module, said response module for sending said one or more desired content data to said requester in a second standard healthcare data format.

2. A system according to claim 1, wherein said worklist module develops work items that include said at least one request for one or more content data.

3. A system according to claim 2, wherein said response module sends said one or more desired content data in response to a command generated by a user in working said work items.

4. A system for responding to a healthcare data inquiry for content data from one or more data stores having one or more data elements stored therein, the system comprising:

(a) a rules module having one or more criteria for interpreting various healthcare data inquiries;

(b) a processing module in communication with said rules module, said processing module for comparing (i) a healthcare data inquiry, including a request for one or more desired content data, to (ii) said one or more criteria to identify one or more data elements associated with said healthcare data inquiry, and retrieving said one or more data elements from the one or more data stores; and

(c) a response module in communication with said processing module, said response module for sending said one or more data elements to a requester in a standard healthcare data inquiry format.

5. A system according to claim 4, wherein said worklist module creates one or more work items associated with said request.

6. A system according to claim 4, wherein said healthcare data inquiry is a healthcare claims attachment inquiry and said rules module, said processing module and said response module are adapted to handle said healthcare claims attachment inquiry.

7. A system according to claim 4, wherein said healthcare data inquiry is a healthcare authorization attachment inquiry and said rules module, said processing module and said response module are adapted to handle said healthcare authorization attachment inquiry.

8. A system for automatically retrieving desired content data for a healthcare claim from one or more data stores having one or more data elements stored therein, the system comprising:

(a) a receiver module for receiving a healthcare data inquiry from a requestor, said healthcare data inquiry including a request for one or more desired content data;

(b) a rules module having one or more criteria for interpreting various healthcare data inquiries,

(c) a comparison module in communication with said receiver module and said rules module, said comparison module for comparing said healthcare data inquiry to said rules to determine one or more data elements associated with said request and to determine which of the one or more data stores includes said one or more data elements;

(d) an acquisition module in communication with said comparison module and the one or more data stores, said acquisition module for retrieving said one or more data elements; and

(e) a response module in communication with said acquisition module, said response module for sending said one or more data elements to said requestor in a standard format.

9. A system according to claim 8, wherein said receiver module is adapted to receive said healthcare data inquiry from said requestor, said requester being a third party payer.

10. A system according to claim 8, wherein said receiver module is adapted to receive said healthcare data inquiry from said requestor, said requester being is a claims financial system.

11. A system according to claim 8, wherein said receiver module is adapted to receive said healthcare data inquiry from said requestor, said requester being an EDI system.

12. A system according to claim 8, further comprising a notification module in communication with said receiver module, wherein said notification module generates a billing system notification.

13. A system according to claim 8, further comprising a tracking module in communication with said receiver module and said comparison module, where said tracking module generates a tracking record associated with said healthcare data inquiry.

14. A system according to claim 8, further comprising an update module that updates said one or more rules with information learned during an acquisition of a particular data element.

15. A system according to claim 8, further comprising a packaging module in communication with said response module, wherein said packaging module bundles a plurality of said one or more data elements for delivery to said requester.

16. A system according to claim 8, further comprising a worklist module in communication with said comparison module, said worklist module being for creating one or more work items associated with said request.

17. A system according to claim 16, wherein said one or more work items each identify said one or more data elements for said request.

18. A system according to claim 8, further comprising a statistics module in communication with the system, said statistics module for collecting statistics associated with requests from a requestor.

19. A system according to claim 18, further comprising an intelligent learning module in communication with said statistics module and designed to communicate with one or more claims creation rules of a claims financial system, said intelligent learning module for analyzing said statistics mid modifying said one or more claims creation rules.

20. A system according to claim 8, wherein said standard format includes a 275 healthcare claims standard.

21. A system according to claim 8, wherein said healthcare data inquiry is a healthcare authorization attachment inquiry.

22. A method of responding to a healthcare data inquiry, the method comprising:

(a) receiving a healthcare data inquiry from a requester, said healthcare data inquiry including a request for one or more content data;

(b) automatedly determining one or more data elements associated with said request using a criteria including one or more rules for interpreting a variety of content data;

(c) automatedly determining a location of said one or more data elements amongst one or more data stores;

(d) retrieving said one or more data elements from said one or more data stores;

(e) formatting said one or more data elements into a claims attachment in a predetermined format; and

(f) transmitting said claims attachment to said requestor.

23. A method according to claim 22, wherein said receiving step involves receiving said request from a third party payer.

24. A method according to claim 22, wherein said receiving step involves receiving said request from a claims financial system.

25. A method according to claim 22, wherein said receiving step involves receiving said request from an EDI system.

26. A method according to claim 22, further comprising creating a tracking record associated with said healthcare data inquiry.

27. A method according to claim 22, further comprising generating a billing system notification, said notification indicating receipt of said healthcare data inquiry.

28. A method according to claim 22, further comprising:

(a) storing said healthcare data inquiry in a first database; and

(b) retrieving said healthcare data inquiry from said first database.

29. A method according to claim 22, further comprising, following said translating step (d), packaging a plurality of said one or more data elements for delivery to said requestor.

30. A method according to claim 22, wherein said predetermined format includes a 275 healthcare claims standard.

31. A system for automatically modifying a claims financial system, the system comprising:

(a) a management module for processing a plurality of healthcare data inquiries from a requestor;

(b) a statistics acquisition module in communication with said system module, said statistics module for collecting statistics associated with said plurality of healthcare data inquiries; and

(c) an intelligent learning module in communication with said statistics module, said intelligent learning module for analyzing said statistics and modifying one or more claims creation rules of a claims financial system.

32. A computer readable medium having computer-executable instructions for implementing a method of managing the exchange of information between healthcare systems, the instructions comprising:

(a) a first set of instructions for receiving a healthcare data inquiry from a requestor, said healthcare data inquiry including a request for one or more content data;

(b) a second set of instructions for automatedly determining one or more data elements associated with said request using a criteria including one or more rules for interpreting a variety of content data;

(c) a third set of instructions for automatedly determining a location of said one or more data elements amongst one or more data stores;

(d) a fourth set of instructions for retrieving said one or more data elements from said one or more data stores;

(e) a fifth set of instructions for formatting said one or more data elements into a claims attachment in a predetermined format; and

(f) a sixth set of instructions for transmitting said claims attachment to said requestor.

33. A computer readable medium according to claim 32, said instructions including a seventh set of instructions for creating a tracking record associated with said healthcare data inquiry.

34. A computer readable medium according to claim 32, said instructions including an eighth set of instructions for generating a billing system notification, said notification indicating receipt of said healthcare data inquiry.

35. A computer readable medium according to claim 32, said instructions including,

(a) a ninth set of instructions for storing said healthcare data inquiry in a first database;

and

(b) a tenth set of instructions for retrieving said healthcare data inquiry from said first database.

36. A computer readable medium according to claim 32, said instructions further comprising an eleventh set of instructions for packaging a plurality of said one or more data elements for delivery to said requestor.