Healthcare provider data submission and billing system and method

• US 20070088564A1
• Filed: 10/13/2005
• Published: 04/19/2007
• Est. Priority Date: 10/13/2005
• Status: Abandoned Application

• Current Assignee: R&G Resources LLC
• Original Assignee: R&G Resources LLC
• Inventors: March, Glenville, Standridge, Richard
• Application Number:
  US11/248,328
• Publication Number:
  US 20070088564A1
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/14 specially adapted for billing systems

Abstract

A healthcare insurance claim processing system and method generates a first set of data fields for display in a healthcare claim form. The first set includes requests for patient billing and medical information, and a request for a medical procedure code. The medical procedure code associated with a medical diagnosis of the patient is entered for at least one field of the first set of data fields. A second set of data fields is generated in accordance with the medical procedure code for display in the healthcare claim form. The second set of data fields includes requests for medical diagnostic information of the patient to assist in diagnosing a medical condition of the patient. The healthcare claim form with information from the first and second sets of data fields is submitted to a payer for payment of the health insurance claim associated with the medical condition of the patient.

Claims

1. A system for processing a healthcare insurance claim, comprising:

a data generation module,

wherein the data generation module is configured to generate a first set of data fields,

wherein the first set of data fields includes requests for billing and medical information associated with a patient, and

wherein at least one data field of the first set of data fields includes a request for a medical procedure code;

a display module in communication with the data generation module,

wherein the display module is configured to display the first set of data fields to a user in a healthcare claim form, and

wherein the medical procedure code associated with a medical diagnosis of the patient is entered into the at least one data field; and

a medical diagnostic module in communication with the data generation module and the display module,

wherein the medical diagnostic module is configured to generate a second set of data fields in accordance with the medical procedure code,

wherein the display module is configured to display the second set of data fields to the user in the healthcare claim form,

wherein the second set of data fields comprises requests for medical diagnostic information associated with the patient,

wherein the medical diagnostic information is configured to assist the user in diagnosing a medical condition of the patient, and

wherein the healthcare claim form with information from the first and second sets of data fields is submitted to a payer for payment of the health insurance claim associated with the medical condition of the patient.

2. The system of claim 1, wherein the medical procedure code comprises one of a limited code, an intermediate code, and a comprehensive code.

3. The system of claim 2, wherein the comprehensive code generates a greater number of requests for medical diagnostic information than for the intermediate code,

and wherein the intermediate code generates a greater number of requests for medical diagnostic information than for the limited code.

4. The system of claim 1, wherein a value of the medical procedure code is associated with a level of detail of requests for medical diagnostic information associated with the patient.

5. The system of claim 4, wherein a high value of the medical procedure code is associated with a basic request for medical diagnostic information associated with the patient.

6. The system of claim 4, wherein a low value of the medical procedure code is associated with a comprehensive request for medical diagnostic information associated with the patient.

7. The system of claim 1, wherein medical procedure codes are associated with medical specialties.

8. The system of claim 1, wherein the medical procedure code comprises a current procedure terminology (CPT) code.

9. The system of claim 1, wherein the medical procedure code comprises a healthcare common procedure coding system (HCPCS) code.

10. The system of claim 1, comprising:

a communication module in communication with the data generation module and the medical diagnostic module,

wherein the communication module is configured to transmit an electronic copy of the healthcare claim form to the payer.

11. The system of claim 1, comprising:

a printing module in communication with the data generation module and the medical diagnostic module,

wherein the printing module is configured to print a hardcopy of the healthcare claim form for submission to the payer.

12. The system of claim 1, comprising:

a correspondence generation module in communication with the data generation module and the medical diagnostic module,

wherein the correspondence generation module is configured to generate correspondence associated with the healthcare claim form, and

wherein the correspondence is populated with information from the first and second sets of data fields.

13. The system of claim 1, wherein the medical diagnostic information associated with the patient comprises information for determining diseases suffered by the patient.

14. The system of claim 1, wherein the medical diagnostic information associated with the patient comprises information for determining whether a complete medical examination was given to the patient.

15. The system of claim 1, wherein the medical diagnostic information associated with the patient comprises information for determining actions taken by a physician in performing a medical examination of a patient.

16. The system of claim 1, wherein the medical diagnostic information associated with the patient comprises information for determining whether a patient is to be enrolled in a disease management program.

17. The system of claim 1, wherein the medical diagnostic module comprises a rules engine.

18. The system of claim 1, wherein the display module is configured to remotely display the healthcare claim form with the first and second sets of data fields through a Web browser via a computer network connection.

19. The system of claim 1, wherein the healthcare claim form comprises a CMS-1500 health insurance claim form.

20. The system of claim 1, wherein the healthcare claim form comprises a UB-92 healthcare insurance claim form.

21. The system of claim 1, wherein the system is complaint with a Health Insurance Portability and Accountability Act (HIPAA).

22. A method of processing a healthcare insurance claim, comprising the steps of:

a.) generating a first set of data fields for display to a user in a healthcare claim form,

wherein the first set of data fields includes requests for billing and medical information associated with a patient, and

wherein at least one data field of the first set of data fields includes a request for a medical procedure code;

b.) entering the medical procedure code associated with a medical diagnosis of the patient into the at least one data field;

c.) generating a second set of data fields in accordance with the medical procedure code for display to the user in the healthcare claim form,

wherein the second set of data fields comprises requests for medical diagnostic information associated with the patient, and

wherein the medical diagnostic information is configured to assist the user in diagnosing a medical condition of the patient; and

d.) submitting the healthcare claim form with information from the first and second sets of data fields to a payer for payment of the health insurance claim associated with the medical condition of the patient.

23. The method of claim 22, wherein the medical procedure code comprises one of a limited code, an intermediate code, and a comprehensive code.

24. The method of claim 22, wherein a value of the medical procedure code is associated with a level of detail of requests for medical diagnostic information associated with the patient.

25. The method of claim 22, wherein step (d) comprises the step of:

d1.) transmitting an electronic copy of the healthcare claim form to the payer.

26. The method of claim 22, wherein step (d) comprises the step of:

d1.) printing a hardcopy of the healthcare claim form for submission to the payer.

27. The method of claim 22, comprising the step of:

e.) generating correspondence associated with the healthcare claim form,

wherein the correspondence is populated with information from the first and second sets of data fields.

28. The method of claim 22, wherein the medical diagnostic information associated with the patient comprises information for determining diseases suffered by the patient.

29. The method of claim 22, wherein the medical diagnostic information associated with the patient comprises information for determining whether a patient is to be enrolled in a disease management program.

30. A system for processing a benefits claim, comprising:

an information generation module,

wherein the information generation module is configured to generate a first set of data fields,

wherein the first set of data fields includes requests for billing and benefits information associated with an individual, and

wherein at least one data field of the first set of data fields includes a request for a benefits code;

a display module in communication with the information generation module,

wherein the display module is configured to display the first set of data fields to a user in a benefits claim form, and

wherein the benefits code associated with a benefit of the individual is entered into the at least one data field; and

a benefit analysis module in communication with the information generation module and the display module,

wherein the benefit analysis module is configured to generate a second set of data fields in accordance with the benefits code,

wherein the display module is configured to display the second set of data fields to the user in the benefits claim form,

wherein the second set of data fields comprises requests for benefits analysis information associated with the individual,

wherein the benefits analysis information is configured to assist the user in analyzing benefits for the individual, and

wherein the benefits claim form with information from the first and second sets of data fields is submitted to a payer for payment of the benefits claim associated with the benefit of the individual.