Systems And Methods For Health Insurance Claim Processing

• US 20120029950A1
• Filed: 07/28/2011
• Published: 02/02/2012
• Est. Priority Date: 07/28/2010
• Status: Abandoned Application

• Current Assignee: Adaptive Intelligence LLC
• Original Assignee: Adaptive Intelligence LLC
• Inventors: Lyle, James G., Schif, Alan
• Application Number:
  US13/193,132
• Publication Number:
  US 20120029950A1
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A method of processing health insurance claims includes receiving, within a claim receiver, a claim submission from a client, the claim submission identifying a policy of the client and details of the health insurance claim. The claim receiver converts, within the claim receiver, the claim submission into a claim charge to facilitate automated processing of the health insurance claim. The claim charge is validated against one or more validation rules to the identify zero, one, or more claim validation exceptions. The validation exceptions are resolved and the claim submission is settled if the validated claim charge and any remaining validation exceptions conform to settlement control data.

Claims

1. A method for health insurance claim processing, comprising:

receiving, within a claim receiver, a claim submission from a client, the claim submission identifying a policy of the client and details of the health insurance claim;

converting, within the claim receiver, the claim submission into a claim charge to facilitate automated processing of the health insurance claim;

validating the claim charge against one or more validation rules to identify zero, one, or more claim validation exceptions;

resolving the claim validation exceptions; and

settling the claim submission based upon the claim charge if the validated claim charge and any remaining validation exceptions conform to settlement control data.

2. The method of claim 1, further comprising issuing a settlement advice based upon the validated claim charge and the settlement control data.

3. The method of claim 1, the step of receiving comprising receiving the claim submission in electronic format from an external submission system.

4. The method of claim 3, wherein the external submission system is a web server, the claim submission being generated online by one of the client and a broker representing the client.

5. The method of claim 1, the step of receiving comprising:

receiving the claim submission in paper format; and

entering data from the paper format claim submission into the claim receiver to form the claim charge.

6. The method of claim 1, the step of determining the claim charge comprising processing the received claim against associated client data and an associated policy plan schedule automatically settles the claim for the claim charge to include claim charge characteristics.

7. The method of claim 1, the step of validating the claim charge further comprising:

identifying claim validation exceptions that require no analyst intervention; and

automatically processing the identified claim validation exceptions.

8. The method of claim 1, the step of validating the claim charge comprising automatically identifying one or more claim validation exceptions that require handling by an analyst.

9. The method of claim 8, the step of resolving the claim validation exceptions further comprising:

presenting each of the one or more claim validation exceptions to the analyst, the analyst selecting an option result; and

performing one or more associated actions to resolve the validation exception.

10. The method of claim 9, the step of presenting comprising presenting two or more of the one or more claim validation exceptions to two or more analysts concurrently, the analysts each determining one or more actions to be taken to resolve each of the presented validation exceptions.

11. A software product comprising instructions, stored on a non-transient computer-readable medium, wherein the instructions, when executed by a computer, perform steps for health insurance claim processing, comprising the steps of:

receiving a claim;

converting the claim to a claim charge;

validating the claim charge to identify claim validation exceptions;

resolving the claim validation exceptions; and

settling the claim.

12. A health insurance claim processing system, the system including a database for storing tables and procedures, wherein the procedures comprise machine readable instructions for providing:

a claim format process for processing a claim submission received from a client into a claim charge;

a claim validation process for validating the claim charge and generating zero, one or more validation exceptions;

an exception resolution process for resolving the one or more validation exceptions; and

a claim settlement process for settling the claim charge once all validation exceptions, if any, are resolved.

13. A health insurance claim processing method, comprising the steps of:

formatting a plurality of claim submissions into a plurality of claim charges stored in an electronic database;

determining at least one validation exception for each of the plurality of claim charges;

grouping the at least one validation exception for each of the plurality of claim charges together with other validation exceptions of the same type from different ones of the plurality of claim charges to form a group of validation exceptions within the database;

processing the group of validation exceptions together; and

updating each of the plurality of claim charges with a respective processed validation exception.