System and method of processing a health insurance claim

• US 20090083079A1
• Filed: 09/21/2007
• Published: 03/26/2009
• Est. Priority Date: 09/21/2007
• Status: Active Grant

• Current Assignee: MediKredit Integrated Healthcare Solutions (Pty) Ltd. (Net 1 UEPS Technologies Incorporated)
• Original Assignee: MediKredit Integrated Healthcare Solutions (Pty) Ltd. (Net 1 UEPS Technologies Incorporated)
• Inventors: Read, Michele, Hanan, Wendy Joy, Luckhoff, Jennifer Anne Noble, Hung, Harriet Sam, Law, Sharon Dawn, Vermeulen, Pieter Lodewickus, Schoeman, Willem Jacobus, Kock, Sanet, Kruger, Helen Mary, Du Plessis, Willemina Jacoba, Olwagen, Jacobus Johannes, Odendaal, Clint Wesley
• Granted Patent: US 8,185,414 B2
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/063 Operations research, analysis or management
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/102 Bill distribution or payments
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

A system and method of processing a health insurance claim are provided. According to the method, transaction data is received that has been transmitted from a third party computer via an open communication channel with the third party computer. The transaction data relates to a health insurance transaction and includes at least a unique identifier for a beneficiary of a health insurance plan to whom the health insurance transaction relates and details of a transaction that is being requested to be processed. The transaction is processed while the communication channel remains open to ascertain if the transaction is an allowable transaction. In response to the transaction submitted, a message is transmitted via the open communication channel to the third party computer wherein the message indicates that the transaction has been processed and that the transaction is an allowable transaction with or without patient collection or that the transaction is not an allowable transaction. The system and method allow for multiple rules to be created for unique sets of circumstances using multiple or singular inputs across multiple health insurance plans using a single system.

Claims

1. A method of processing a health insurance transaction, the method including:

receiving transaction data transmitted from a third party computer via an open communication channel with the third party computer, the transaction data relating to a health insurance transaction, the transaction data including at least a unique identifier for a beneficiary of a health insurance plan to whom the health insurance transaction relates and details of a transaction that is being requested to be processed;

processing the transaction while the communication channel remains open to ascertain if the transaction is an allowable transaction;

in response to the transaction being allowable, transmitting a message via the open communication channel to the third party computer wherein the message indicates that the transaction has been processed and that the transaction is an allowable transaction with or without patient collection or that the transaction is not an allowable transaction.

2. A method according to claim 1 wherein the transaction being requested is the payment of an amount of funds to the member or on behalf of the member to a third party and wherein the transaction data includes details of the medical service or medical product for which payment is being requested.

3. A method according to claim 2 wherein the processing of the transaction to ascertain if the transaction is an allowable transaction with or without patient collection includes using the details of the member'"'"'s health insurance plan to ascertain if the medical service or medical product is covered in terms of the member'"'"'s health insurance plan.

4. A method according to claim 1 further including:

defining a plurality of criteria;

creating a plurality of rules wherein at least some of the rules include at least one of the plurality of criteria; and

applying at least one rule to the transaction request.

5. A method according to claim 4 wherein at least some of the rules include a plurality of criteria that are applied sequentially to determine if the transaction match the criteria and if so whether the transaction is an allowable transaction with or without patient collection.

6. A method according to claim 4 wherein different rules include at least some of the same criteria

7. A method according to claim 6 wherein only after all of the criteria of a rule have been applied to the transaction is the next rule applied to the transaction in a predefined sequence.

8. A method according to claim 4 wherein at least one of the rules includes one or more sub rules and wherein these sub rules are applied in a configured sequence.

9. A method according to claim 3 wherein if the transaction is an allowable transaction:

while the communication channel is open, transmitting a message to a server of a financial administration system via a second communication channel to determine if the member has funds available to pay the amount of the transaction;

receiving a response from the server of the financial administration system via the second communication channel indicating whether the member has funds available either in full or in part or no funds available to pay the amount of the transaction; and

wherein the message transmitted to the third party computer via the open communication channel includes information on whether or not the member has sufficient funds available to cover the amount of the transaction.

10. A method according to claim 9 wherein if the server of the financial administration system is unavailable or too slow to respond, the transaction request is processed against last data stored in a database.

11. A method according to claim 1 wherein the results of the transaction are stored on a database associated with the third party computer and on a database associated with a central server.

12. A method according to claim 11 wherein the results of the transaction are stored on a database associated with a financial administration system.

13. A system for processing a health insurance transaction, the system, including:

a data receiving module for receiving transaction data transmitted from a third party computer via an open communication channel, the transaction data relating to a health insurance transaction, the transaction data including at least a unique identifier for a beneficiary of a health insurance plan to whom the health insurance transaction relates and details of a transaction that is being requested to be processed;

a processor for processing the transaction while the communication channel remains open to ascertain if the transaction is an allowable transaction;

a data transmitting module that in response to the transaction being allowable, transmits a message via the open communication channel to the third party computer wherein the message indicates that the transaction has been processed and that the transaction is an allowable transaction with or without patient collection or that the transaction is not an allowable transaction.

14. A system according to claim 13 wherein the transaction being requested is the payment of an amount of funds to the member or on behalf of the member to a third party and wherein the data receiving module receives transaction data including details of the medical service or medical product for which payment is being requested.

15. A system according to claim 14 wherein the processor processes the transaction to ascertain if the transaction is an allowable transaction with or without patient collection using the details of the member'"'"'s health insurance plan to ascertain if the medical service or medical product is covered in terms of the member'"'"'s health insurance plan.

16. A system according to claim 13 wherein the processor processes the transaction by:

defining a plurality of criteria;

creating a plurality of rules wherein some of the rules include at least one of the plurality of criteria; and

applying at least one rule to the transaction request.

17. A system according to claim 16 wherein at least some of the rules include a plurality of criteria that are applied sequentially to determine if the transaction match the criteria and if so whether the transaction is an allowable transaction with or without patient collection.

18. A system according to claim 16 wherein different rules include at least some of the same criteria.

19. A system according to claim 18 wherein only after all of the criteria of a rule have been applied to the transaction is the next rule applied to the transaction in a predefined sequence.

20. A system according to claim 16 wherein at least one of the rules includes one or more sub rules and wherein these sub rules are applied in a configured order.

21. A system according to claim 13 wherein:

the data transmitting module further, in response to the transaction being an allowable transaction, and while the communication channel is open, transmits a message to a server of a financial administration system via a second communication channel to determine if the member has funds available to pay the amount of the transaction;

the data receiving module receives a response from the server of the financial administration system via the second communication channel indicating whether the member has funds available either in full or in part or no funds available to pay the amount of the transaction; and

the data transmitting module further transmits via the open communication channel to the third party computer information including whether or not the member has sufficient funds available to cover the amount of the transaction.

22. A system according to claim 21 wherein if the server of the financial administration system is unavailable or too slow to respond, the processor processes the transaction request against last data stored in a database.

23. A system according to claim 13 wherein the results of the transaction are stored on a database associated with the processor.