Provider Data Management and Routing

• US 20130191136A1
• Filed: 01/23/2012
• Published: 07/25/2013
• Est. Priority Date: 01/23/2012
• Status: Abandoned Application

• Current Assignee: Conduent Business Services, LLC (Conduent, Inc.)
• Original Assignee: Affiliated Computer Systems, Inc. (Conduent, Inc.)
• Inventors: Apshago, Bernie, Cockerham, Lucas, Fryar, Thomas
• Application Number:
  US13/356,329
• Publication Number:
  US 20130191136A1
• 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

A provider data management and routing system comprising a provider data consolidation and routing unit configured to consolidate healthcare provider data for a plurality of payers and to route the consolidated healthcare provider data to the payers, a provider interface coupled to the provider data management and routing unit and configured to forward the healthcare provider data to the provider data management and routing unit, and a plurality of payer interfaces coupled to the provider data management and routing unit and configured to receive the managed and routed healthcare provider data from the provider data consolidation and routing unit.

Claims

1. A provider data management and routing system comprising:

a provider data consolidation and routing unit configured to consolidate healthcare provider data for a plurality of payers and to route the consolidated healthcare provider data to the payers;

a provider interface coupled to the provider data management and routing unit and configured to forward the healthcare provider data to the provider data management and routing unit; and

a plurality of payer interfaces coupled to the provider data management and routing unit and configured to receive the managed and routed healthcare provider data from the provider data consolidation and routing unit.

2. The provider data management and routing system of claim 1, wherein the provider data consolidation and routing unit is further configured to provide consolidated outreach to a provider via the provider interface to request healthcare provider data.

3. The provider data management and routing system of claim 1, wherein the provider data consolidation and routing unit comprises a local rules engine configured to maintain a plurality of local rules associated with corresponding payers, and wherein the local rules are used to determine a workflow for handling the healthcare provider data and to provide outreach to a provider.

4. The provider data management and routing system of claim 1, wherein the provider data consolidation and routing unit comprises a global rules engine configured to maintain a plurality of common global rules associated with at least some of the payers, and wherein the common global rules are used to determine a workflow for handling the healthcare provider data and to provide outreach to a provider.

5. The provider data management and routing system of claim 1 further comprising a communications network coupled to the provider data consolidation and routing unit, the provider interface, and the payer interfaces and configured to allow communications and exchange of healthcare provider data between the provider data management and routing unit, the provider interface, and the payers interfaces.

6. An apparatus comprising a processor configured to:

receive data from a healthcare provider;

implement a consolidated interaction to consolidate the data based on a plurality of local rules and global rules associated with a plurality of payers of the healthcare provider;

implement a consolidated outreach to the healthcare provider based on the local rules and global rules associated with the payers of the healthcare provider;

receive a response to the consolidated outreach from the healthcare provider;

forward the consolidated data and the response to the corresponding payers; and

forward the consolidated outreach to the healthcare provider.

7. The apparatus of claim 6, wherein the consolidated interaction comprises a plurality of workflow actions that comprise at least one of an email action, a mail action, a fax action, a call center action, a website action, and a response action.

8. The apparatus of claim 7, wherein the workflow actions are implemented to forward the consolidated data to the payers, provide consolidated outreach to the healthcare provider, or both, and wherein the workflow actions are implemented electronically, by a worker, or both.

9. The apparatus of claim 6, wherein the consolidated interaction comprises converting the received data into a transactional packet and processing the transaction packet based on the local rules and global rules associated with the payers to obtain an output transaction packet comprising the consolidated data.

10. The apparatus of claim 6, wherein the consolidated data comprise new information about the healthcare provider that are needed by the payers, updated information about the healthcare provider that are needed by the payers, or both.

11. The apparatus of claim 6, wherein the consolidated data comprise address information, telephone number information, tax number information about the healthcare provider, or combinations thereof.

12. The apparatus of claim 6, wherein the local rules comprise different requirements for different payers, and wherein the requirements determine format, documentation, or both for the received data from the healthcare provider.

13. The apparatus of claim 6, wherein the global rules comprise common requirements for different payers, and wherein the requirements determine format, documentation, or both for the received data from the healthcare provider.

14. A method for managing and routing healthcare provider data comprising:

receiving data from one or more healthcare providers that are needed by one or more payer organizations of the healthcare providers;

processing the data based on a plurality of local rule and a plurality of global rules both associated with the payer organizations; and

providing consolidated outreach to the healthcare provider to request missing information in the data, needed documentation, or both according to the local and global rules.

15. The method of claim 14 further comprising providing outreach to the healthcare provider to request more information if there is an error in the received data.

16. The method of claim 14, wherein the consolidated outreach comprises sending an email notification to the healthcare provider to ask from the healthcare provider to both respond with an address change request on a letterhead and include an effective date in the address change request, and wherein the consolidated outreach also indicates to the healthcare provider that the address change request will be sent to a first payer and a second payer and that the payers'"'"' records will be updated.

17. The method of claim 14 further comprising:

consolidating the processed data for the payers; and

forwarding the consolidated data to the payers.

18. The method of claim 17, wherein processing and consolidating the data comprises converting the received data into a determined input packet format suitable for processing and converting the data into a determined output packet format suitable for forwarding the data.

19. The method of claim 17, wherein processing and consolidating the data comprises implementing a workflow of a plurality of actions according to the local and global rules.

20. The method of claim 17, wherein processing and consolidating the data comprises maintaining the data into one or more local information repositories corresponding to the payers.