Healthcare claim and remittance processing system and associated method

• US 20070050219A1
• Filed: 08/29/2006
• Published: 03/01/2007
• Est. Priority Date: 08/29/2005
• Status: Active Grant

• Current Assignee: Optuminsight, Inc. (UnitedHealth Group Incorporated)
• Original Assignee: Optuminsight, Inc. (UnitedHealth Group Incorporated)
• Inventors: Brown, Darby, Yurjevich, Steven, Sohr, James
• Granted Patent: US 8,364,498 B2
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A system for processing healthcare claims and remittances comprises a database and an electronic portal. The database contains previously received healthcare claims from a plurality of healthcare providers and previously received remittances from a plurality of payers. The electronic portal, connected to the database, receives a healthcare claim from a provider or a remittance from a payer, and splits the received claim or remittance into a plurality of data elements. The portal assigns a unique identifier and a shared identifier to each of the data elements of the received claim or remittance. The portal performs a duplicate claim edit and/or a third party liability edit on the received claim, or performs a duplicate remittance edit an/or a third party payment edit on the received remittance. Based on the result of the edits, the portal submits the received claim to a payer or submits the received remittance to a provider.

Claims

1. A system for processing healthcare claims and remittances, the system comprising:

a database containing previously received healthcare claims from a plurality of healthcare providers and previously received remittances from a plurality of payers; and

an electronic portal connected to the database, the electronic portal configured to receive a healthcare claim from a healthcare provider and to split the received claim into a plurality of data elements, the data elements comprising at least a patient identifier, a healthcare provider identifier, a date of service, and an amount payable;

the electronic portal further configured to perform at least one of a duplicate claim edit or a third party liability edit on the received claim; and

the electronic portal further configured to, based on the result of the duplicate claim edit or the third party liability edit, submit the received claim to a payer.

2. The system of claim 1, wherein the electronic portal is further configured to assign a unique identifier and a shared identifier to each of the plurality of data elements of the received claim;

and wherein the electronic portal is further configured to provide the plurality of data elements and associated unique and shared identifiers to the database to be stored

3. The system of claim 1, wherein the electronic portal is further configured to set a status indicator for each of the plurality of data elements of the received claim to indicate that the claim has been submitted to the payer.

4. The system of claim 1, wherein performing the duplicate claim edit comprises searching the database for a previously received claim having a same patient identifier and a same date of service as the received claim and having a status indicator indicative of having been submitted to the payer;

and wherein the electronic portal is further configured to submit the received claim to the payer only if the database does not contain a previously received claim having the same patient identifier and the same date of service as the received claim and having a status indicator indicative of having been submitted to the payer.

5. The system of claim 4, wherein the electronic portal is further configured to notify the healthcare provider if the database contains a previously received claim having the same patient identifier and the same date of service as the received claim and having a status indicator indicative of having been submitted to the payer.

6. The system of claim 1, wherein performing the third party liability edit comprises determining if one or more third party payers is responsible for paying at least a portion of the amount payable associated with the received claim.

7. The system of claim 6, wherein determining if one or more third party payers is responsible for paying comprises at least one of:

(a) determining if the received claim contains a third party liability indicator;

(b) comparing an insurance carrier listed on the received claim to a stored list of insurance carriers that exclusively function as third party payers;

(c) sending a third party liability inquiry to a payer associated with the received claim;

or (d) searching the database for previously received healthcare claims corresponding to the same patient identifier as the received claim, and determining if any such previously received claims are associated with a third party payer.

8. The system of claim 6, wherein performing the third party liability edit further comprises:

if at least two third party payers are responsible for paying a portion of the amount payable associated with the received claim, determining which of the third party payers is a primary payer and which is a secondary payer; and

if at least three third party payers are responsible for paying a portion of the amount payable associated with the received claim, determining which of the third party payers is a tertiary payer;

wherein submitting the received claim to a payer comprises submitting the received claim to the primary payer.

9. The system of claim 2, wherein the electronic portal is further configured to determine if any necessary data is missing from the received claim and to send a missing data request to the healthcare provider.

10. The system of claim 9, wherein the electronic portal is further configured to receive missing data from the healthcare provider and split the received missing data into a plurality of data elements;

wherein the electronic portal is further configured to assign a unique identifier to each of the plurality of data elements of the missing data; and

wherein the electronic portal is further configured to assign the previously assigned shared identifier to each of the plurality of data elements of the missing data.

11. The system of claim 1, wherein the electronic portal is further configured to resubmit the received claim to the payer and notify the healthcare provider of the resubmission if a predetermined amount of time has elapsed since the received claim was submitted to the payer.

12. The system of claim 2, wherein the electronic portal is further configured to receive a remittance from a payer and split the received remittance into a plurality of data elements, the data elements comprising at least a patient identifier, a healthcare provider identifier, a date of service, and an amount being paid;

wherein the electronic portal is further configured to assign a unique identifier to each of the plurality of data elements of the received remittance;

wherein the electronic portal is further configured to assign the shared identifier to each of the plurality of data elements of the received remittance,

wherein the electronic portal is further configured to perform at least one of a duplicate remittance edit or a third party payment edit on the received remittance;

wherein the electronic portal is further configured to, based on the result of the duplicate remittance edit, submitting the received remittance to the healthcare provider; and

wherein the electronic portal is further configured to store the plurality of data elements and associated unique and shared identifiers in the database.

13. The system of claim 12, wherein the electronic portal is further configured to set a status indicator for each of the plurality of data elements of the received remittance to indicate that the remittance has been submitted to the healthcare provider.

14. The system of claim 12, wherein performing the duplicate remittance edit comprises searching the database for a previously received remittance having a same patient identifier and a same date of service as the received remittance and having a status indicator indicative of having been submitted to the healthcare provider;

and wherein the electronic portal is further configured to submit the received remittance to the healthcare provider only if the database does not contain a previously received remittance having the same patient identifier and the same date of service as the received remittance and having a status indicator indicative of having been submitted to the healthcare provider.

15. The system of claim 14, wherein the electronic portal is further configured to notify the payer if the database contains a previously received remittance having the same patient identifier and the same date of service as the received remittance and having a status indicator indicative of having been submitted to the healthcare provider.

16. The system of claim 12, wherein performing the third party payment edit comprises:

determining if any portion of the amount payable remains outstanding after receiving the remittance;

determining if one or more third party payers is responsible for paying the outstanding portion;

wherein the electronic portal is further configured to, if one third party payer is responsible for paying the outstanding portion, submit a claim for the outstanding portion to the one third party payer responsible for paying the outstanding portion; and

wherein the electronic portal is further configured to, if two or more third party payers are responsible for paying the outstanding portion, submit a claim for the outstanding portion to the third party payer having primary responsibility to pay the outstanding portion.

17. A method for processing healthcare claims and remittances, the method comprising:

providing a database of previously received healthcare claims from a plurality of healthcare providers and previously received remittances from a plurality of payers;

receiving a healthcare claim from a healthcare provider;

splitting the received claim into a plurality of data elements, the data elements comprising at least a patient identifier, a healthcare provider identifier, a date of service, and an amount payable;

performing at least one of a duplicate claim edit or a third party liability edit on the received claim; and

based on the result of the duplicate claim edit or the third party liability edit, submitting the received claim to a payer.

18. The method of claim 17, wherein the method further comprises:

assigning a unique identifier and a shared identifier to each of the plurality of data elements of the received claim; and

storing the plurality of data elements and associated unique and shared identifiers in the database.

19. The method of claim 17, wherein the method further comprises:

setting a status indicator for each of the plurality of data elements of the received claim to indicate that the claim has been submitted to the payer

20. The method of claim 17, wherein performing the duplicate claim edit comprises searching the database for a previously received claim having a same patient identifier and a same date of service as the received claim and having a status indicator indicative of having been submitted to the payer;

and wherein the received claim is submitted to the payer only if the database does not contain a previously received claim having the same patient identifier and the same date of service as the received claim and having a status indicator indicative of having been submitted to the payer.

21. The method of claim 20, wherein the method further comprises:

notifying the healthcare provider if the database contains a previously received claim having the same patient identifier and the same date of service as the received claim and having a status indicator indicative of having been submitted to the payer.

22. The method of claim 17, wherein performing the third party liability edit comprises determining if one or more third party payers is responsible for paying at least a portion of the amount payable associated with the received claim.

23. The method of claim 22, wherein determining if one or more third party payers is responsible for paying comprises at least one of:

(a) determining if the received claim contains a third party liability indicator;

(b) comparing an insurance carrier listed on the received claim to a stored list of insurance carriers that exclusively function as third party payers;

(c) sending a third party liability inquiry to a payer associated with the received claim;

or (d) searching the database for previously received healthcare claims corresponding to the same patient identifier as the received claim, and determining if any such previously received claims are associated with a third party payer.

24. The method of claim 22, wherein performing the third party liability edit further comprises:

if at least two third party payers are responsible for paying a portion of the amount payable associated with the received claim, determining which of the third party payers is a primary payer and which is a secondary payer; and

if at least three third party payers are responsible for paying a portion of the amount payable associated with the received claim, determining which of the third party payers is a tertiary payer;

wherein submitting the received claim to a payer comprises submitting the received claim to the primary payer.

25. The method of claim 18, further comprising:

determining if any necessary data is missing from the received claim; and

sending a missing data request to the healthcare provider.

26. The method of claim 25, further comprising:

receiving missing data from the healthcare provider;

splitting the received missing data into a plurality of data elements;

assigning a unique identifier to each of the plurality of data elements of the missing data; and

assigning the previously assigned shared identifier to each of the plurality of data elements of the missing data.

27. The method of claim 17, further comprising:

resubmitting the received claim to the payer and notifying the healthcare provider of the resubmission if a predetermined amount of time has elapsed since the received claim was submitted to the payer.

28. The method of claim 18, further comprising:

receiving a remittance from a payer;

splitting the received remittance into a plurality of data elements, the data elements comprising at least a patient identifier, a healthcare provider identifier, a date of service, and an amount being paid;

assigning a unique identifier to each of the plurality of data elements of the received remittance;

assigning the shared identifier to each of the plurality of data elements of the received remittance;

performing at least one of a duplicate remittance edit or a third party payment edit on the received remittance;

based on the result of the duplicate remittance edit, submitting the received remittance to the healthcare provider; and

storing the plurality of data elements and associated unique and shared identifiers in the database.

29. The method of claim 28, wherein the method further comprises:

setting a status indicator for each of the plurality of data elements of the received remittance to indicate that the remittance has been submitted to the healthcare provider.

30. The method of claim 28, wherein performing the duplicate remittance edit comprises searching the database for a previously received remittance having a same patient identifier and a same date of service as the received remittance and having a status indicator indicative of having been submitted to the healthcare provider;

and wherein the received remittance is submitted to the healthcare provider only if the database does not contain a previously received remittance having the same patient identifier and the same date of service as the received remittance and having a status indicator indicative of having been submitted to the healthcare provider.

31. The method of claim 30, wherein the method further comprises:

notifying the payer if the database contains a previously received remittance having the same patient identifier and the same date of service as the received remittance and having a status indicator indicative of having been submitted to the healthcare provider.

32. The method of claim 28, wherein performing the third party payment edit comprises:

determining if any portion of the amount payable remains outstanding after receiving the remittance;

determining if one or more third party payers is responsible for paying the outstanding portion;

and wherein the method further comprises;

if one third party payer is responsible for paying the outstanding portion, submitting a claim for the outstanding portion to the one third party payer responsible for paying the outstanding portion; and

if two or more third party payers are responsible for paying the outstanding portion, submitting a claim for the outstanding portion to the third party payer having primary responsibility to pay the outstanding portion.

33. A computer program product for processing healthcare claims and remittances, the computer program product comprising at least one computer-readable storage medium having computer-readable program code portions stored therein, the computer-readable program code portions comprising:

a first executable portion capable of providing a database of previously received healthcare claims from a plurality of healthcare providers and previously received remittances from a plurality of payers;

a second executable portion capable of receiving a healthcare claim from a healthcare provider;

a third executable portion capable of splitting the received claim into a plurality of data elements, the data elements comprising at least a patient identifier, a healthcare provider identifier, a date of service, and an amount payable;

a fourth executable portion capable of performing at least one of a duplicate claim edit or a third party liability edit on the received claim; and

a fifth executable portion capable of, based on the result of the duplicate claim edit or the third party liability edit, submitting the received claim to a payer.

34. The computer program product of claim 33, further comprising:

a sixth executable portion capable of assigning a unique identifier and a shared identifier to each of the plurality of data elements of the received claim; and

a seventh executable portion capable of storing the plurality of data elements and associated unique and shared identifiers in the database.

35. The computer program product of claim 33, further comprising:

an eighth executable portion capable of setting a status indicator for each of the plurality of data elements of the received claim to indicate that the claim has been submitted to the payer

36. The computer program product of claim 33, wherein performing the duplicate claim edit comprises searching the database for a previously received claim having a same patient identifier and a same date of service as the received claim and having a status indicator indicative of having been submitted to the payer;

and wherein the fifth executable portion submits the received claim to the payer only if the database does not contain a previously received claim having the same patient identifier and the same date of service as the received claim and having a status indicator indicative of having been submitted to the payer.

37. The computer program product of claim 36, further comprising:

a sixth executable portion capable of notifying the healthcare provider if the database contains a previously received claim having the same patient identifier and the same date of service as the received claim and having a status indicator indicative of having been submitted to the payer.

38. The computer program product of claim 33, wherein performing the third party liability edit comprises determining if one or more third party payers is responsible for paying at least a portion of the amount payable associated with the received claim.

39. The computer program product of claim 38, wherein determining if one or more third party payers is responsible for paying comprises at least one of:

(a) determining if the received claim contains a third party liability indicator;

(b) comparing an insurance carrier listed on the received claim to a stored list of insurance carriers that exclusively function as third party payers;

(c) sending a third party liability inquiry to a payer associated with the received claim;

or (d) searching the database for previously received healthcare claims corresponding to the same patient identifier as the received claim, and determining if any such previously received claims are associated with a third party payer.

40. The computer program product of claim 38, wherein performing the third party liability edit further comprises:

if at least two third party payers are responsible for paying a portion of the amount payable associated with the received claim, determining which of the third party payers is a primary payer and which is a secondary payer; and

if at least three third party payers are responsible for paying a portion of the amount payable associated with the received claim, determining which of the third party payers is a tertiary payer;

wherein submitting the received claim to a payer comprises submitting the received claim to the primary payer.

41. The computer program product of claim 34, further comprising:

an eighth executable portion capable of determining if any necessary data is missing from the received claim; and

a ninth executable portion capable of sending a missing data request to the healthcare provider.

42. The computer program product of claim 41, further comprising:

a tenth executable portion capable of receiving missing data from the healthcare provider;

a eleventh executable portion capable of splitting the received missing data into a plurality of data elements;

a twelfth executable portion capable of assigning a unique identifier to each of the plurality of data elements of the missing data; and

a thirteenth executable portion capable of assigning the previously assigned shared identifier to each of the plurality of data elements of the missing data.

43. The computer program product of claim 33, further comprising:

a sixth executable portion capable of resubmitting the received claim to the payer and notifying the healthcare provider of the resubmission if a predetermined amount of time has elapsed since the received claim was submitted to the payer.

44. The computer program product of claim 34, further comprising:

an eighth executable portion capable of receiving a remittance from a payer;

a ninth executable portion capable of splitting the received remittance into a plurality of data elements, the data elements comprising at least a patient identifier, a healthcare provider identifier, a date of service, and an amount being paid;

a tenth executable portion capable of assigning a unique identifier to each of the plurality of data elements of the received remittance;

an eleventh executable portion capable of assigning the shared identifier to each of the plurality of data elements of the received remittance;

a twelfth executable portion capable of performing at least one of a duplicate remittance edit or a third party payment edit on the received remittance;

a thirteenth executable portion capable of, based on the result of the duplicate remittance edit, submitting the received remittance to the healthcare provider; and

a fourteenth executable portion capable of storing the plurality of data elements and associated unique and shared identifiers in the database.

45. The computer program product of claim 44, further comprising:

a fifteenth executable portion capable of setting a status indicator for each of the plurality of data elements of the received remittance to indicate that the remittance has been submitted to the healthcare provider.

46. The computer program product of claim 44, wherein performing the duplicate remittance edit comprises searching the database for a previously received remittance having a same patient identifier and a same date of service as the received remittance and having a status indicator indicative of having been submitted to the healthcare provider;

and wherein the received remittance is submitted to the healthcare provider only if the database does not contain a previously received remittance having the same patient identifier and the same date of service as the received remittance and having a status indicator indicative of having been submitted to the healthcare provider.

47. The computer program product of claim 46, further comprising:

a fifteenth executable portion capable of notifying the payer if the database contains a previously received remittance having the same patient identifier and the same date of service as the received remittance and having a status indicator indicative of having been submitted to the healthcare provider.

48. The computer program product of claim 44, wherein performing the third party payment edit comprises:

determining if any portion of the amount payable remains outstanding after receiving the remittance;

determining if one or more third party payers is responsible for paying the outstanding portion;

wherein, if one third party payer is responsible for paying the outstanding portion, the thirteenth executable portion submits a claim for the outstanding portion to the one third party payer responsible for paying the outstanding portion; and

wherein if two or more third party payers are responsible for paying the outstanding portion, the thirteenth executable portion submits a claim for the outstanding portion to the third party payer having primary responsibility to pay the outstanding portion.