Computerized medical insurance system including means to automatically update member eligibility files at pre-established intervals

• US 5,070,452 A
• Filed: 10/17/1989
• Issued: 12/03/1991
• Est. Priority Date: 06/30/1987
• Status: Expired due to Term

• Current Assignee: Northern Patent Management, Incorporated
• Original Assignee: NGS American, Inc. (Trustmark Mutual Holding Company)
• Inventors: Alcott, William D. III, Doyle, Findley C. Jr.
• Primary Examiner(s): Hayes, Gail O.
• Application Number:
  US07/422,625
• Time in Patent Office: 777 Days
• Field of Search: 364/401, 364/406, 364/408, 364/413.01, 235/375
• 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

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. Apparatus for updating a central data base consisting of the identities of beneficiaries who at a point in time are members of an employment group having post-membership option rights for continuing health care benefits comprising:

a file of predetermined time spans between active and pending states of benefit plan eligibility based on the status of association between the beneficiary and the employment group;

a clock function means responsive to changes in beneficiary member status for updating the beneficiary plan eligibility state in the file at said predetermined time spans; and

a two-way data communication link between at least one benefit provider and the file for inputting member identification information and receiving current data representing the status of the beneficiary relevant to the employment group and plan eligibility during both active and pending status periods.

2. Apparatus as defined in claim 1 further including means for generating a notification to a group member upon the occurrence of a change in status.

3. Apparatus as defined in claim 2 wherein the notification includes information regarding continuing benefit plan options.

4. For use in combination with a central data base which is maintained by a health care benefit plan administrator and which consists of at least (a) employment group member identification data, (b) employment group member benefit eligibility status data, (c) defined benefit payment amounts and (d) a clock function which modifies the plan eligibility status data for individual employment group members at appropriate times related to a change in employment group membership status:

a two-way data communication apparatus for location at a benefit provider station which is remote from the central data base and which includes;

means for inputting beneficiary identification data and sending such identification data to the central data base for verification as to the association between the proposed beneficiary and the employment group benefit plan and, according to said clock function, the status of beneficiary eligibility;

means for receiving and displaying proposed beneficiary eligibility confirmation from the central data base as a result of the inputting of beneficiary identification data;

means for inputting proposed benefit identification data and sending such benefit identification data to the central data base;

means for receiving and displaying the payment amount data from the central data base which corresponds to the previously inputted proposed benefit identification data; and

means for inputting and sending to the central data base a payment request based on the proposed benefit payment amount.

5. Apparatus as defined in claim 4 further including a two-way data communication link between said devices and the central data base.

6. Apparatus as defined in claim 5 further including means for updating the contents of the central data base to show both active and pending states of benefit plan eligibility for each beneficiary whose identification data is in the central data base.

7. Apparatus as defined in claim 6 further including notice generating means interconnected with said central data base for receiving data representing changes in status of a beneficiary relative to the employment group and for generating notices of benefit plan eligibility and options associated with said eligibility for transmission to beneficiaries/employment group members;

and

clock means for initiating activation of said notice generating means a regulated time span following an employment group membership status change.

8. For use in combination with the central data base which is maintained by a health care benefit plan administrator and which consists of at least (a) employment group member identification data, (b) employment group member benefit eligibility status data, (c) defined benefit payment amounts and (d) a clock function means which modifies the plan eligibility status data for individual employment group members at appropriate times related to a change in employment group membership status;

a two-way data communication apparatus for location at a benefit provider station which is remote from the central data base and which includes;

means for inputting beneficiary identification data and sending such identification data to the central data base for verification as to the association between the proposed beneficiary and the employment group benefit plan and, according to said clock function means, the status of beneficiary eligibility;

means for receiving and displaying proposed beneficiary eligibility confirmation from the central data base as a result of the inputting of beneficiary identification data;

means for inputting proposed benefit identification data and sending such benefit identification data to the central data base; and

means for receiving and displaying the payment amount data from the central data base which corresponds to the previously inputted proposed benefit identification data.

9. For use in combination with the central data base which is maintained by a health care benefit plan administrator and which consists of at least (a) employment group member identification data, (b) employment group member benefit eligibility status data, (c) defined benefit payment amounts and (d) a clock function means which modifies the plan eligibility status data for individual employment group members at appropriate times related to a change in employment group membership status;

a two-way data communication apparatus for location at a benefit provider station which is remote from the central data base and which includes;

means for inputting beneficiary identification data and sending such identification data to the central data base for verification as to the association between the proposed beneficiary and the employment group benefit plan and, according to said clock function means, the status of beneficiary eligibility; and

means for receiving and displaying proposed beneficiary eligibility confirmation from the central data base as a result of the inputting of beneficiary identification data.