Systems And Methods For Health Insurance Claim Processing
First Claim
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.
1 Assignment
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Accused Products
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.
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Citations
13 Claims
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1. A method for health insurance claim processing, comprising:
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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. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10)
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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:
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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.
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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:
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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.
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13. A health insurance claim processing method, comprising the steps of:
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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.
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Specification