ENHANCED SYSTEMS AND METHODS FOR PROCESSING OF HEALTHCARE INFORMATION

• US 20080033750A1
• Filed: 06/01/2007
• Published: 02/07/2008
• Est. Priority Date: 06/02/2006
• Status: Abandoned Application

• Current Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Original Assignee: Trizetto Group Incorporated (Cognizant Technology Solutions Corp.)
• Inventors: Hoerle, Dale, Spirek, Dan, Burriss, Melony
• Application Number:
  US11/757,154
• Publication Number:
  US 20080033750A1
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Enhanced systems and methods for processing of healthcare information are provided. According to one embodiment, a method comprises receiving, at a claim processing system that is operable to adjudicate a claim for payment from an insurer for services rendered to a healthcare consumer, a request for estimated healthcare payment information. The request may pertain to a service that has not been rendered to the healthcare consumer. The request for the estimated healthcare information may be received (e.g., electronically, such as via a web interface, and/or otherwise via a communication network, such as the Internet) from the healthcare consumer or from a healthcare service provider. The method further comprises processing the request by the claim processing system for determining the requested estimated healthcare payment information. The method further comprises communicating, from the claim processing system, a response to the request that includes the estimated healthcare payment information.

Claims

1. A method comprising:

receiving, at a claim processing system that is operable to adjudicate a claim for payment from an insurer for services rendered to a healthcare consumer, a request for estimated healthcare payment information for a service;

processing said request by said claim processing system for determining the requested estimated healthcare payment information, wherein the healthcare payment information is not committed for payment by said insurer; and

communicating, from the claim processing system, a response to the request that includes the estimated healthcare payment information.

2. The method of claim 1 wherein said service for which the estimated healthcare payment information is requested is a service that has not been rendered to the healthcare consumer.

3. The method of claim 1 wherein said receiving, processing, and communicating are performed in real-time.

4. The method of claim 1 wherein the healthcare payment information pertains to a specific healthcare service for a specific healthcare consumer, and wherein the receiving comprises:

receiving the request before the service is rendered to the healthcare consumer.

5. The method of claim 1 wherein the receiving comprises:

receiving the request from the healthcare consumer.

6. The method of claim 1 wherein the receiving comprises:

receiving the request from a healthcare service provider.

7. The method of claim 1 wherein the receiving a request comprises:

receiving a mock claim for the service, wherein the mock claim is in a common format as an actual claim for a service that has been rendered to the healthcare consumer with an indicator that indicates the mock claim is for service that has not been rendered to the healthcare consumer.

8. The method of claim 1 wherein the receiving a request comprises:

receiving a mock claim for the service, wherein the mock claim is in a common format as an actual claim for a service that has been rendered to the healthcare consumer with an indicator that indicates the mock claim is not to be presently committed for payment by the insurer.

9. The method of claim 1 wherein the healthcare payment information comprises an estimate of the healthcare consumer'"'"'s liability for the service.

10. The method of claim 1 wherein the claim processing system computes the estimate.

11. The method of claim 1 wherein the communicating comprises:

communicating the healthcare consumer'"'"'s liability for all items included in the service.

12. The method of claim 11 wherein the items included in the service comprise one or more of procedures, pharmaceuticals, and medical equipment.

13. The method of claim 1 wherein the communicating comprises:

communicating an explanation of benefits.

14. A method comprising:

receiving, at a claim processing system that is operable to adjudicate a claim for payment from an insurer for services rendered to a healthcare consumer, a mock claim for a service, wherein the mock claim has information associated therewith that indicates that it is not to be presently committed by the claim processing system for payment by the insurer;

processing said mock claim by claim adjudication logic of said claim processing system to determine an estimate of healthcare payment information for the service; and

outputting, from the claim processing system, the estimated healthcare payment information for the service.

15. The method of claim 14 wherein the mock claim is for a service that has not been rendered to the healthcare consumer

16. The method of claim 14 wherein said receiving, processing, and outputting are performed in real-time.

17. The method of claim 14 wherein the estimated healthcare payment information pertains to a specific healthcare service for a specific healthcare consumer, and wherein the receiving comprises:

receiving the request before the service is rendered to the healthcare consumer.

18. The method of claim 14 wherein the receiving comprises:

receiving the request from the healthcare consumer.

19. The method of claim 14 wherein the receiving comprises:

receiving the request from a healthcare service provider.

20. The method of claim 14 wherein the mock claim is in a common format as an actual claim for a service that has been rendered to the healthcare consumer with information associated therewith that indicates the mock claim is for service that has not been rendered to the healthcare consumer.

21. The method of claim 14 wherein the mock claim is in a common format as an actual claim for a service that has been rendered to the healthcare consumer with an indicator that indicates the mock claim is not to be committed by the claim processing system.

22. The method of claim 14 wherein the estimated healthcare payment information comprises an estimate of the healthcare consumer'"'"'s liability for the service identified in the mock claim.

23. The method of claim 22 wherein the claim processing system computes the estimate.

24. The method of claim 14 wherein the estimated healthcare payment information comprises the healthcare consumer'"'"'s liability for all items included in the service defined in the mock claim.

25. The method of claim 24 wherein the items included in the service defined in the mock claim comprise one or more of procedures, pharmaceuticals, and medical equipment.

26. The method of claim 14 wherein the outputting further comprises;

outputting an explanation of benefits for the mock claim.

27. The method of claim 14 further comprising:

the claim processing system not committing the estimated healthcare payment information determined for the mock claim.

28. The method of claim 27 further comprising:

receiving, at the claim processing system, a request to convert the mock claim to an actual claim.

29. The method of claim 28 further comprising:

responsive to the request to convert, the claim processing system processing the mock claim as an actual claim for service rendered to the healthcare consumer to determine actual healthcare payment information.

30. The method of claim 29 further comprising:

the claim processing system committing the determined actual healthcare payment information.

31. The method of claim 14 wherein said processing said mock claim by said claim adjudication logic further comprises:

determining any error code that would be generated by the claim processing system if the mock claim were an actual claim; and

outputting, by said claim processing system, an identification of the determined error code.

32. A method comprising:

receiving, at a claim processing system is operable to adjudicate a claim for payment from an insurer for services rendered to a healthcare consumer, a mock claim for a service, wherein the mock claim has information associated therewith that indicates that processing of said mock claim by said claim processing system is to be interrupted prior to committing the mock claim for payment by the insurer;

processing said mock claim by claim adjudication logic of said claim processing system to determine information pertaining to said mock claim;

interrupting processing of said mock claim by said claim processing system prior to committing the mock claim for payment by the insurer; and

outputting, from the claim processing system, the determined information.

33. The method of claim 32 wherein said determined information pertaining to said mock claim comprises an estimate of healthcare payment information for the service identified in said mock claim.

34. The method of claim 32 further comprising:

determining, from information associated with said mock claim, a stage in a processing flow of said adjudication logic at which to perform said interrupting of said processing.

35. The method of claim 32 wherein the outputting comprises:

communicating consumer liability for all items included in the service identified in the mock claim.

36. The method of claim 35 wherein the items included in the service comprise one or more of procedures, pharmaceuticals, and medical equipment.

37. The method of claim 32 wherein the outputting further comprises:

communicating an explanation of benefits.

38. A system comprising:

adjudication logic that is operable to adjudicate a claim for payment from an insurer for services rendered to a healthcare consumer; and

an interface to said adjudication logic that enables receipt by said adjudication logic of a mock claim for a service that is not to be presently committed for payment by the insurer;

wherein said adjudication logic is operable to process the mock claim to determine an estimate of healthcare payment information for the service.

39. The system of claim 38 wherein the adjudication logic does not commit the mock claim.

40. The system of claim 38 wherein the mock claim is for a service that has not been rendered to the healthcare consumer

41. The system of claim 40 wherein the adjudication logic processes the mock claim as a claim for a service that has been rendered to the healthcare consumer, except the adjudication logic does not commit the mock claim.

42. The system of claim 38 wherein the adjudication logic is operable to output the estimated healthcare payment information for the service.

43. The system of claim 38 wherein the adjudication logic is operable to process the mock claim in real-time.

44. The system of claim 38 further comprising:

an interface to said adjudication logic that enables receipt by said adjudication logic of a request to commit the mock claim for payment by the insurer.

45. A system comprising:

adjudication logic that is operable to adjudicate a claim for payment from an insurer to a service provider for services rendered to a healthcare consumer;

an interface to said adjudication logic that enables receipt by said adjudication logic of a mock claim for a service, wherein the mock claim has information associated therewith that indicates that processing of said mock claim by said adjudication logic is to be interrupted prior to committing the mock claim for payment by the insurer;

wherein the adjudication logic is operable to process a received mock claim to determine information pertaining to said mock claim;

wherein the adjudication logic is operable to interrupt its processing of said mock claim prior to committing the mock claim for payment by the insurer; and

wherein the adjudication logic is operable to output the determined information pertaining to said mock claim.

46. The system of claim 45 wherein the mock claim is for a service that has not been rendered to the healthcare consumer.

47. The system of claim 45 wherein said adjudication logic is operable to process the mock claim to determine an estimate of healthcare payment information for the service.