Data Restructuring for Consistent Formatting

• US 20130204642A1
• Filed: 02/01/2013
• Published: 08/08/2013
• Est. Priority Date: 02/03/2012
• Status: Active Grant

• Current Assignee: Experian Health, Inc. (Experian plc)
• Original Assignee: Passport Health Communications (Experian plc)
• Inventors: Farmer, Richard W., Feenstra, Donavon R.
• Granted Patent: US 10,380,320 B2
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

Consistently coded eligibility data is provided. Eligibility responses may be received from various payers comprising inconsistently coded eligibility benefit (EB) information provided in EB segments in various locations in the responses. A data restructuring engine may be operable to receive an eligibility response and restructure the response into a consistent format. Co-pay, co-insurance, benefit limitations, and benefit specific deductibles may be clarified by embedding coded strings in one or more message segments attached to EB segments. Service types, network indicators, place of service codes, and message text may be removed when a coded strings is created. Recoded eligibility responses may be provided to healthcare providers, providing coverage, eligibility, and benefit data in a consistent and standardized form, regardless of the payer sending the eligibility response.

Claims

1. A method for providing consistently coded eligibility data, the method comprising:

receiving eligibility data in an eligibility response;

parsing the eligibility data in the eligibility response for one or more eligibility benefit data elements;

creating one or more coded strings; and

creating a recoded eligibility response comprising the one or more coded strings.

2. The method of claim 1, wherein parsing the eligibility data in the eligibility response for one or more eligibility benefit data elements comprises parsing eligibility benefit segments and message segments for one or more of:

place of service information;

service type information;

provider type information;

relation of provider to payer information;

relation of provider to patient information;

reason for service information;

or

service category information.

3. The method of claim 2, wherein parsing eligibility data in the eligibility response for one or more eligibility benefit data elements comprises parsing eligibility benefit segments for code values coding one or more of:

place of service information;

service type information;

provider type information;

relation of provider to payer information;

relation of provider to patient information;

reason for service information;

or

service category information.

4. The method of claim 2, wherein parsing eligibility data in the eligibility response for one or more eligibility benefit data elements comprises parsing message segments for free-form message text identifying critical benefit details.

5. The method of claim 2, wherein parsing eligibility data in the eligibility response for one or more eligibility benefit data elements comprises parsing message segments for free-form message text identifying benefit details identified in an eligibility benefit segment.

6. The method of claim 2, further comprising:

identifying a payer sending the eligibility response; and

looking up location information in a table according to the payer sending the eligibility response, the location information providing possible locations in the eligibility response to parse eligibility benefit data elements.

7. The method of claim 1, wherein creating one or more coded strings comprises providing a coded string in one or more message segments, the coded string codifying one or more of:

place of service information;

service type information;

provider type information;

relation of provider to payer information;

relation of provider to patient information;

reason for service information;

service category information;

free-form message text identifying critical benefit details;

or

free-form message text identifying benefit details identified in an eligibility benefit segment.

8. The method of claim 7, wherein providing a coded string in one or more message segments comprises providing a coded string comprising a coded value in one or more of:

a place of service dimension;

a service type dimension;

a provider type dimension;

a relation of provider to payer dimension;

a relation of provider to patient dimension;

a reason for service dimension;

or

a service category dimension.

9. The method of claim 8, further comprising providing a tag indicating that the message segment comprises a coded string.

10. The method of claim 8, further comprising providing a tag indicating whether the coded string includes inclusion or exclusion information.

11. The method of claim 8, further comprising providing a separator between each dimension.

12. The method of claim 1, further comprising:

removing eligibility benefit code values, free-form message text identifying critical benefit details, or free-form message text identifying benefit details identified in an eligibility benefit segment that has been codified in a coded string; and

providing the recoded eligibility response to a healthcare provider.

13. A system for providing consistently coded eligibility data, the system comprising:

one or more processors; and

a memory coupled to the one or more processors, the one or more processors operable to;

receive eligibility data in an eligibility response;

parse the eligibility data in the eligibility response for one or more eligibility benefit data elements;

create one or more coded strings; and

create a recoded eligibility response comprising the one or more coded strings.

14. The system of claim 13, wherein the one or more processors are further operable to parse eligibility benefit segments and message segments for one or more of:

place of service information;

service type information;

provider type information;

relation of provider to payer information;

relation of provider to patient information;

reason for service information;

or

service category information.

15. The system of claim 14, the one or more processors are further operable to parse eligibility benefit segments for code values coding one or more of:

place of service information;

service type information;

provider type information;

relation of provider to payer information;

relation of provider to patient information;

reason for service information;

or

service category information.

16. The system of claim 14, the one or more processors are further operable to parse message segments for free-form message text identifying critical benefit details and free-form message text identifying benefit details identified in an eligibility benefit segment.

17. The system of claim 14, the one or more processors are further operable to:

identify a payer sending the eligibility response; and

look up location information in a table according to the payer sending the eligibility response, the location information providing possible locations of eligibility benefit data elements in the eligibility response.

18. The system of claim 13, wherein:

the coded string comprises one or more coded values in one or more of;

a place of service dimension;

a service type dimension;

a provider type dimension;

a relation of provider to payer dimension;

a relation of provider to patient dimension;

a reason for service dimension;

or

a service category dimension; and

the coded values codifying one or more of;

place of service information;

service type information;

provider type information;

relation of provider to payer information;

relation of provider to patient information;

reason for service information;

service category information;

free-form message text identifying critical benefit details;

or

free-form message text identifying benefit details identified in an eligibility benefit segment.

19. The system of claim 13, wherein the one or more processors are further operable to:

remove eligibility benefit code values, free-form message text identifying critical benefit details, or free-form message text identifying benefit details identified in an eligibility benefit segment that has been codified in a coded string; and

provide the recoded eligibility response to a healthcare provider.

20. A computer readable medium containing computer executable instructions which, when executed by a computer, perform a method for providing consistently coded eligibility data, the method comprising:

receiving eligibility data in an eligibility response;

identifying a payer sending the eligibility response;

looking up possible locations of eligibility benefit data elements in the eligibility response in a table;

parsing the eligibility data in the eligibility response for one or more eligibility benefit data elements;

creating one or more coded strings, the one or more coded strings comprising coded values for one or more of;

place of service information;

service type information;

provider type information;

relation of provider to payer information;

relation of provider to patient information;

reason for service information;

service category information;

free-form message text identifying critical benefit details;

or

free-form message text identifying benefit details identified in an eligibility benefit segment;

removing eligibility benefit code values, free-form message text identifying critical benefit details, or free-form message text identifying benefit details identified in an eligibility benefit segment that has been codified in a coded string; and

creating a recoded eligibility response comprising the one or more coded strings.