Method, system and computer program product for creating software for processing an insurance claim

• US 20070260646A1
• Filed: 04/25/2006
• Published: 11/08/2007
• Est. Priority Date: 04/25/2006
• Status: Active Grant

• Current Assignee: Xerox State & Local Solutions, Inc. (Conduent, Inc.)
• Original Assignee: ACS State & Local Solutions Incorporated (Conduent, Inc.)
• Inventors: Szlam, Aleksander
• Granted Patent: US 7,856,617 B2
• Time in Patent Office: Days
• US Class Current: 1/1
• CPC Class Codes: G06Q 10/087 Inventory or stock management, e.g. order filling, procurement or balancing against orders
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A method, system and computer program product are provided for creating software that can be used when processing insurance claims. In particular, the software generated is capable of recognizing and flagging certain situations or sets of conditions when they arise in an insurance claim that is being processed. These situations or sets of conditions, as well as the type of flag, or “edit,” that should be posted when each occurs, are defined in a decision table from which the software is automatically generated. A method of processing an insurance claim using the automatically generated software is also provided.

Claims

1. A method of creating software for processing an insurance claim, said method comprising:

creating a decision table based on a combination of conditions defining when a respective one of a plurality of edits should be posted to the insurance claim;

providing the decision table to a software generator; and

automatically generating computer programming instructions based upon the decision table and configured to cause the respective edit to be posted based on the combinations of conditions from the decision table upon execution thereof.

2. The method of claim 1, wherein each edit comprises a code that is associated with a particular situation that is determined to have occurred based on the combination of conditions from the decision table associated with the respective edit.

3. The method of claim 2, wherein automatically generating computer programming instructions comprises automatically generating computer programming instructions configured to cause the code associated with the respective edit to be inserted into the insurance claim.

4. The method of claim 1, wherein creating a decision table is repeated for each of the plurality of edits, such that a different decision table is created for each edit based on a different combination of conditions defining when the edit, with which the decision table is associated, should be posted.

5. The method of claim 4, wherein providing the decision table to the software generator is repeated for each of the different decision tables, such that for each of the different decision tables, a different set of computer programming instructions is automatically generated that causes the respective edit, with which the decision table is associated, to be posted based on the combination of conditions from the decision table.

6. A system for creating software for processing an insurance claim, said system comprising:

a software generator; and

a decision table instantiated in a memory device and accessible by the software generator, said decision table defining a combination of conditions that must be met in order for a respective one of a plurality of edits to be posted to the insurance claim,

wherein the software generator automatically generates computer programming instructions based upon the decision table and configured to cause the respective edit to be posted based on the combination of conditions from the decision table upon execution thereof.

7. The system of claim 6, wherein each edit comprises a code that is associated with a particular situation that is determined to have occurred when the combination of conditions from the decision table associated with the respective edit have been met.

8. The system of claim 7, wherein automatically generating computer programming instructions comprises automatically generating computer programming instructions configured to cause the code associated with the respective edit to be inserted into the insurance claim.

9. The system of claim 6 further comprising a plurality of decision tables, wherein each of the plurality of decision tables defines a different combination of conditions that must be met in order for a respective one of the plurality of edits to be posted.

10. The system of claim 9, wherein for each of the plurality of decision tables, the software generator automatically generates a different set of computer programming instructions that causes the respective edit, with which the decision table is associated, to be posted based on the combination of conditions from the decision table.

11. A computer program product for creating software for processing an insurance claim, wherein the computer program product comprises 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 for receiving a decision table, said decision table based on a combination of conditions defining when a respective one of a plurality of edits should be posted to the insurance claim; and

a second executable portion for automatically generating computer programming instructions based upon the decision table and configured to cause the respective edit to be posted based on the combination of conditions from the decision table upon execution thereof.

12. The computer program product of claim 11 further comprising:

a third executable portion for enabling a user to create the decision table.

13. The computer program product of claim 11, wherein each edit comprises a code that is associated with a particular situation that is determined to have occurred based on the combination of conditions from the decision table associated with the respective edit.

14. The computer program product of claim 13, wherein automatically generating computer programming instructions comprises automatically generating computer programming instructions configured to cause the code associated with the respective edit to be inserted into the insurance claim.

15. A method of processing an insurance claim, said method comprising:

determining which of a plurality of processes are associated with the insurance claim;

determining which of a plurality of edits are associated with each of the processes associated with the insurance claim;

accessing a decision table for each of the associated edits based on a combination of conditions defining when the respective edits should be posted to the insurance claim during processing of the claim;

automatically generating computer programming instructions based upon the respective decision tables and configured to cause respective edits to be posted based on the combination of conditions from the respective decision tables upon execution thereof; and

evaluating the insurance claim with the automatically generated computer programming instructions.

16. The method of claim 15, wherein the plurality of processes include validating data, verifying that a recipient is qualified for coverage, verifying that a provider is authorized to perform a service, and determining for what benefit a claimant qualifies.

17. The method of claim 15, wherein each edit comprises a code that is associated with a particular situation that is determined to have occurred based on the combination of conditions from the decision table associated with the respective edit.

18. The method of claim 17, wherein automatically generating computer programming instructions comprises automatically generating computer programming instructions configured to cause the code associated with the respective edit to be inserted into the insurance claim.

19. The method of claim 15, wherein determining which of a plurality of processes are associated with the insurance claim comprises determining which of the plurality of processes are associated with the claim based on the type of insurance claim.