Automated processing of provider billings
First Claim
1. A method for insurance company processing of provider billings for determining an allowable payment for services rendered by the provider to a member of a group of individuals insured by the insurance company, which method comprises;
- identifying a complexity of rules including basic rules applicable to occurrences encountered by a member of the group generating a need for provider services, and further including rules modifying the basic rules applicable to variations in the services provided by the provider;
converting the rules into computer readable computable data;
generating a computer program including the data representing the rules and including process steps for scanning the data to determine applicability of the rules represented by the data, said program responsive to specific input codes representing a claim of a member of the group, a qualified provided and the services provided;
inputting the computer program into a computer;
receiving manually prepared provider billings having provided billing information including identification of a claim of a member, the provider, and the services rendered, and manually inputting that information to the computer in the form of said specific input codes; and
computer processing the information by application of the computer program to thereby apply the rules to the provider billing information and determine from the information the allowable payment permitted by the rules.
2 Assignments
0 Petitions
Accused Products
Abstract
The inclusion of computer capability to process Workers'"'"' Compensation claims wherein a complexity of administrative rules determine maximum allowable benefits, the processing of which is not feasible for manual processing. The rules are converted to computer computations entered into the computer'"'"'s memory. A computer process is devised to systematically examine the rules as they apply to a specific billing. In particular, the various modifiers that affect the allowable pay out are determined through this computer processing. Pre-stored information on prior billings for the same injury is considered for further modification of the allowable billing amount.
167 Citations
6 Claims
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1. A method for insurance company processing of provider billings for determining an allowable payment for services rendered by the provider to a member of a group of individuals insured by the insurance company, which method comprises;
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identifying a complexity of rules including basic rules applicable to occurrences encountered by a member of the group generating a need for provider services, and further including rules modifying the basic rules applicable to variations in the services provided by the provider; converting the rules into computer readable computable data; generating a computer program including the data representing the rules and including process steps for scanning the data to determine applicability of the rules represented by the data, said program responsive to specific input codes representing a claim of a member of the group, a qualified provided and the services provided; inputting the computer program into a computer; receiving manually prepared provider billings having provided billing information including identification of a claim of a member, the provider, and the services rendered, and manually inputting that information to the computer in the form of said specific input codes; and computer processing the information by application of the computer program to thereby apply the rules to the provider billing information and determine from the information the allowable payment permitted by the rules. - View Dependent Claims (2, 3, 4, 5, 6)
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Specification