Insurance administration system with means to allow an employer to directly communicate employee status data to centralized data storage means

• US 4,916,611 A
• Filed: 06/30/1987
• Issued: 04/10/1990
• Est. Priority Date: 06/30/1987
• Status: Expired due to Term

• Current Assignee: Northern Patent Management, Incorporated
• Original Assignee: Northern Group Services Incorporated
• Inventors: Alcott, William D. III, Doyle, Findley C. Jr.
• Primary Examiner(s): Smith, Jerry
• Assistant Examiner(s): Hayes, Gail O.
• Application Number:
  US07/068,240
• Time in Patent Office: 1,015 Days
• Field of Search: 364/401, 364/403, 364/413, 364/413.02
• US Class Current: 705/2
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

The computerized insurance claim processing system links the physician'"'"'s office and the provider of insurance coverage by means of a central administration computer. The system provides up-to-date information to the provider of health care services as to insurance coverage of a patient. The system also allows real time modification of the information, including the identity of patients covered and the type of insurance benefits.

Claims

1. In a health care benefits administration system of the type having a computer system for storing and processing information in a database containing records of patients and medical benefits, the improvement comprising:

said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;

said eligibility file including a benefits status record for storing one of a plurality of states, including at least an active state and a pending state, for each patient;

a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;

said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;

said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patient;

notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state.

2. The administration system of claim 1 wherein the administration system is accessible to service providers which provide medical services to patients, the improvement further comprising:

at least one service provider terminal communicating on line with said computer system and directly accessible by said service provider for input of data indicating the identity of a patient and for receiving from said computer system an indication of the eligibility of said patient for medical benefits;

said computer system being preprogrammed to interrogate said status record in response to input of data from said service provider terminal and to supply an indication at said service provider terminal of whether said status record for said patient is at said pending state.

3. The benefits system of claim 1 wherein said status record is capable of storing a special active state in addition to said active state and said pending state, said special active state indicating that a given patient has been terminated by the benefits sponsor and said patient has elected to continue to receive medical benefits.

4. The administration system of claim 3 wherein said status record is further capable of storing a terminated state in addition to said active state, said special active state and said pending state;

wherein said computer system includes time clock means for ascertaining elapsed time; and

wherein said computer system is preprogrammed to interrogate said status record and to automatically change a pending state to a terminated state in response to a predetermined elapsed time.

5. The administration system of claim 1 wherein said status record is capable of storing a terminated state in addition to said active state and said pending state;

wherein said computer system includes time clock means for ascertaining elapsed time; and

wherein said computer system is preprogrammed to interrogate said status record and to automatically change a pending state to a terminated state in response to a predetermined elapsed time.

6. The administration system of claim 1 wherein said computer system includes time clock means for ascertaining elapsed time;

and

wherein said computer system is preprogrammed to interrogate said status record and to automatically remove a patient from said eligibility file when said status record for that patient has been in the pending state for a predetermined elapsed time.

7. In a medical benefits administration system of the type having a computer system for storing and processing information in a database containing records of patients and medical benefits, and having a plurality of service provider terminals attached to said computer system for use by service providers in interacting with said computer system, the improvement comprising:

said database having a patient file identifying each of said plurality of medical benefits plans under which each patient has coverage;

said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;

said eligibility file including a benefits status record for storing one of a plurality of states, including at least an active state and a pending state, for each patient;

a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;

said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;

said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patient;

notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state;

said computer system being preprogrammed to receive from said service provider terminal identity data indicative of the identity of a given patient and service data indicative of the services for which payment is requested;

said computer system being preprogrammed to access said patient file in response to said identity data and to ascertain the medical benefits plans under which said patient has coverage.

8. The administration system of claim 7 wherein said patient file includes a record capable of identifying one of a plurality of medical benefits plans as a primary plan and at least one other of said plurality of medical benefits plans as a secondary plan;

and

wherein said computer system is preprogrammed to coordinate benefits for a given patient between said primary and secondary plans.

9. The administration system of claim 7 wherein said service provider terminal communicates on line with said computer system and receives from said computer system an indication of the eligibility of said patient for medical benefits.

10. The administration system of claim 7 wherein said service provider terminal communicates on line with said computer system and receives from said computer system an indication of the amounts payable under such medical benefits plans for the services indicated by said service data.

11. In a medical benefits administration system of the type having a computer system for storing and processing information in a database containing records of patients and medical benefits, and having a plurality of service provider terminals attached to said computer system for use by service providers in interacting with said computer system, the improvement comprising:

said database having a plan parameters file having a record of coverage parameters including amounts paid for specified treatments under a plurality of medical benefits plans;

said database having a patient file identifying each of said plurality of medical benefits plans under which each patient has coverage;

said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;

said eligibility file including a benefits status record for storing one of a plurality of states, including at least an active state and a pending state, for each patient;

a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;

said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;

said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patient;

notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state;

said computer system being preprogrammed to receive from said service provider terminal identity data indicative of the identity of a given patient and service data indicative of the services for which payment is requested;

said computer system being preprogrammed to access said patient file in response to said identity data and to ascertain the medical benefits plans under which said patient has coverage;

said computer system being preprogrammed to access said plan parameters file for each of the medical benefits plans so ascertained to determine the amounts payable under such medical benefits plans for the services indicated by said service data.

12. The administration system of claim 11 wherein said patient file includes a record capable of identifying one of a plurality of medical benefits plans as a primary plan and at least one other of said plurality of medical benefits plans as a secondary plan;

and

wherein said computer system is preprogrammed to coordinate benefits for a given patient between said primary and secondary plans.

13. The administration system of claim 11 wherein said service provider terminal communicates on line with said computer system and receives from said computer system an indication of the eligibility of said patient for medical benefits.

14. The administration system of claim 11 wherein said service provider terminal communicates on line with said computer system and receives from said computer system an indication of the amounts payable under such medical benefits plans for the services indicated by said service data.

15. In a medical benefits administration system of the type having a computer system for storing and processing information in a database containing records of patients and medical benefits, and having a plurality of service provider terminals attached to said computer system for use by service providers in interacting with said computer system, the improvement comprising:

said database having a plan parameters file having a record of coverage parameters including amounts paid for specified treatments under a plurality of medical benefits plans;

said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;

said eligibility file including a benefits status record for providing one of a plurality of states, including at least an active state and a pending state, for each patient;

a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;

said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;

said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patient;

notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state;

said computer system being preprogrammed to receive from said service provider terminal identity data indicative of the identity of a given patient and service data indicative of the services for which payment is requested;

said computer system being preprogrammed to access said plan parameters file for each of the medical benefits plans so ascertained to determine the amounts payable under such medical benefits plans for the services indicated by said service data.

16. The administration system of claim 15 wherein said service provider terminal communicates on line with said computer system and receives from said computer system an indication of the eligibility of said patient for medical benefits.

17. The administration system of claim 15 wherein said service provider terminal communicates on line with said computer system and receives from said computer system an indication of the amounts payable under such medical benefits plans for the services indicated by said service data.

18. In a medical benefits administration system of the type having a computer system for storing and processing information in a database containing records of patients and medical benefits, and having a plurality of service provider terminals attached to said computer system for use by service providers in interacting with said computer system, the improvement comprising:

said database having a plan parameters file having a record of coverage parameters including amounts paid for specified treatments under a plurality of medical benefits plans;

said database having a patient file identifying each of said plurality of medical benefits plans under which each patient has coverage;

said database having means for establishing a hierarchy among each of said plurality of medical benefits plans for a given patient, identifying at least a primary plan and a secondary plan;

said database having an eligibility file of a plurality of patients for which medical benefits are provided by a given benefits sponsor;

said eligibility file including a benefits status record for storing one of a plurality of states, including at least an active state and a pending state, for each patient;

a benefits sponsor terminal communicating on line with said computer system and directly accessible by said benefits sponsor for input of data indicating that benefits provided by said sponsor for a particular patient should be added or terminated;

said computer system being preprogrammed to automatically alter said status record for said given patient to said active state when said data input by said benefits sponsor indicates that benefits are to be added for said patient;

said computer system being preprogrammed to automatically alter said status record for said given patient to said pending state when said data input by said benefits sponsor indicates that benefits are to be terminated for said patient;

notification generating means controlled by said computer system for automatically providing notice to a patient of a change in said status record from an active state to a pending state;

said computer system being preprogrammed to receive from said service provider terminal identity data indicative of the identity of a given patient and service data indicative of the services for which payment is requested;

said computer system being preprogrammed to access said patient file in response to said identity data and to ascertain the medical benefits plans under which said patient has coverage;

said computer system being preprogrammed to access said plan parameters file for each of the medical benefits plans so ascertained to determine the amounts payable under such medical benefits plans for the services indicated by said service data;

said computer system being preprogrammed to access said hierarchy establishing means in so determining the amounts payable, whereby said secondary plan is applied to amounts not payable under said primary plan to thereby maximize the total amounts payable on behalf of said patient without cumulative ovepayment by said primary and secondary plans.