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Automated claims processing system

  • US 20100145734A1
  • Filed: 11/24/2008
  • Published: 06/10/2010
  • Est. Priority Date: 11/28/2007
  • Status: Active Application
First Claim
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1. An automated system having a database of information for processing a claim under a beneficial coverage contract issued by an insurance company or financial institution, such system comprising:

  • (a) identification of the beneficial coverage contract and facts characterizing a claimed loss event under the beneficial coverage contract;

    (b)means for assigning a risk assessment score via a statistical model or set of business rules by the insurance company or financial institution to the claim under the beneficial coverage contract for characterizing the risk that the claim is fraudulent or erroneous using statistical modeling techniques;

    (c) means for associating with the risk assessment score for the claim a total confidence level (“

    TCL”

    ) value required by the insurance company or financial institution for verifying the claimed loss event;

    (d) means for pre-selecting a plurality of corroborating data sources with each one characterized by a confidence level value chosen or statistically modeled by the insurance company or financial institution for such data source'"'"'s ability to verify the claimed loss event;

    (e) means for automatically consulting one of the corroborating data sources to determine whether its informational content matches information provided by the claimant for the claimed loss event, and only in the event of a positive match, the pre-assigned confidence level value of the corroborating data source being added to an accumulated verification value (“

    AVV”

    ) score for the claim;

    (f) means for determining a remaining verification value (“

    RVV”

    ) required to verify the claimed loss event by subtracting the AVV score from the TCL value (i.e., RVV=TCL−

    AVV);

    (g) iterative repetition of steps (e) and (f) with successive corroborating data sources if the RVV value is less than the TCL value;

    (h) in the event that the AVV score for the claims equals at least the required TCL value, treating the claim as verified for adjudication in accordance with the rules of the beneficial coverage contract for ultimate disposition; and

    (i) treating the claim as unverified if the accumulated AVV value does not equal or exceed the required TCL value with no other corroborating data source available having a sufficient pre-assigned confidence level value that would bridge the difference between the AVV value and required TCL value if it was consulted by the system.

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