Processing an insurance claim using electronic versions of supporting documents

• US 7,346,523 B1
• Filed: 01/11/2002
• Issued: 03/18/2008
• Est. Priority Date: 01/11/2002
• Status: Expired due to Fees

• Current Assignee: PPS Data LLC (Zions Bancorporation, N.A.)
• Original Assignee: P5, Inc.
• Inventors: Provost, Wayne A., Trimble, Ryan M.
• Primary Examiner(s): Thomas; Joseph
• Assistant Examiner(s): TOMASZEWSKI, MICHAEL
• Application Number:
  US10/044,357
• Time in Patent Office: 2,258 Days
• Field of Search: 705 2- 3, 705/4
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/06 Buying, selling or leasing transactions
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Methods and systems for requesting and delivering supporting documents to an insurance carrier to enable the carrier to process an insurance claim for services rendered by a physician provider. Hard copies of supporting documents are converted to electronic images that are accessible by the carrier through the Internet, thereby eliminating the need for communication between the provider and the carrier through regular mail. The images are indexed based upon the insurance claim, the provider, the patient, and/or the carrier to enable the carrier to access the images associated with a specific insurance claim efficiently. In addition, the insurance claim can be pre-adjudicated prior to delivering the claim to the carrier for processing and can be approved and paid before the carrier processes the claim.

Claims

1. In a server system that communicates with a client system associated with a health care provider and is adapted to facilitate processing of an insurance claim, a method of delivering a supporting document to a carrier to enable the carrier to process an insurance claim and for advancing payment to the physician, the method comprising the acts of:

the server system determining that an insurance claim for services rendered by the health care provider is in condition for advance payment prior to adjudication by a carrier;

the server system transmitting claim information associated with the insurance claim to a payment entity, such that the payment entity can advance money to the health care provider prior to the carrier making payment on the insurance claim;

the server system generating a list of supporting documents needed to process the insurance claim based on information included in the insurance claim, the list of supporting documents identified from a supporting document database having data indicative of supporting documents needed to process the insurance claim;

the server system providing the list of supporting documents to the client system;

the server system, upon receiving the supporting documents identified in the list of supporting documents and associated with the insurance claim in an electronic format from the client system, storing an electronic image of the supporting documents;

the server system causing the payment entity to advance payment to the health care provider prior to adjudication of the insurance claim by the carrier, wherein a portion of the advance payment is reserved for at least one of service fees, unpaid balances, or interest on unpaid balances in an account that is not accessible to the health care provider; and

the server system transmitting the insurance claim and a notice of the availability of the electronic image to the carrier, such that the carrier can access the image, process the insurance claim, and make payment on the insurance claim to the payment entity, thereby paying for the advance payment previously made to the health care provider.

2. A method as recited in claim 1, wherein the act of determining that the insurance claim is in condition for advance payment comprises the act of determining whether a patient identified by the insurance claim is a beneficiary of the carrier.

3. A method as recited in claim 2, wherein the act of determining that the insurance claim is in condition for advance payment further comprises the act of determining whether treatment information identified by the insurance claim corresponds to health care services that are approved by the carrier.

4. A method as recited in claim 1, further comprising, if it is determined that the insurance claim is not in condition for payment, performing the acts of:

prior to transmitting the insurance claim to the carrier, notifying the client system that the insurance claim is not in condition for payment; and

receiving an amended insurance claim from the client system in which one or more errors in the insurance claim have been corrected, such that the amended insurance claim is in condition for payment.

5. A method as recited in claim 4, further comprising the act of transmitting a suggested revised treatment code that corresponds to the health care services rendered to the client system.