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Correcting and monitoring status of health care claims

  • US 7,739,132 B2
  • Filed: 10/17/2003
  • Issued: 06/15/2010
  • Est. Priority Date: 10/17/2002
  • Status: Active Grant
First Claim
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1. In a medical insurance payment system having a plurality of medical providers and a plurality of insurance payers, wherein medical reimbursement claims are submitted electronically from practice management computer systems of the plurality of medical providers to claims processing computer systems of the plurality of insurance payers for payment determinations, wherein an intermediary claim management system is in electronic communication between the practice management computer systems of the plurality of medical providers and the claims processing computer systems of the plurality of insurance payers, wherein the intermediary claim management system includes a claim management database for storing claim information and a processor for performing a computer-implementable method for improving medical reimbursement claim processing between medical providers and insurance providers, comprising the steps of:

  • (a) prior to receiving a particular medical reimbursement claim at the intermediary claim management system from a particular medical provider;

    (i) receiving a plurality of medical reimbursement claims at the intermediary claim management system electronically from the practice management computer systems of the plurality of medical providers, each of the plurality of claims including data about a patient of a respective provider, a service provided to the patient by the respective provider, and a respective payer to whom the claim must be submitted for payment;

    (ii) submitting each of the plurality of claims electronically from the intermediary claim management system to the claims processing computer system of each respective payer for payment determination;

    (iii) receiving a substantive response at the intermediary claim management system from the claims processing computer system of each respective payer for each respective claim, each substantive response including one or more of claim acknowledgement data, claim acceptance data, and claim rejection data, the claim rejection data including one or more payer claim rejection identifiers relating to specific issues in the claim identified by the respective payer;

    (iv) for each substantive response that includes claim rejection data, associating via the intermediary claim management system processor each payer claim rejection identifier with one of a plurality of predefined claim rejection categories and one of a plurality of predefined rejection descriptions in the claim management database as a function of claim rejection identifier type;

    (b) receiving the particular medical reimbursement claim at the intermediary claim management system electronically from the practice management computer system of the particular medical provider;

    (i) generating a claim record for the particular claim via the intermediary claim management system processor, and storing the claim record in the claim management database;

    (ii) submitting the particular claim electronically from the intermediary claim management system to the claims processing computer system of a particular insurance payer for payment determination;

    (iii) receiving a particular substantive response at the intermediary claim management system from the claims processing computer system of the particular insurance payer for the particular claim;

    (iv) if the particular substantive response includes claim rejection data, extracting one or more payer claim rejection identifiers from the claim rejection data via the intermediary claim management system processor;

    (iv) determining a corresponding predefined claim rejection category and predefined rejection description for each extracted claim rejection identifier for the particular claim based on the predefined claim rejection category and predefined rejection description associated with the extracted claim rejection identifier in the claim management database;

    (v) updating the claim record for the particular claim in the claim management database to include the corresponding predefined claim rejection category and predefined rejection description determined for each extracted claim rejection identifier; and

    (vi) displaying each corresponding predefined claim rejection category and predefined rejection description for the particular claim to the particular medical provider based on the updated claim record for the particular claim,whereby the particular medical provider is able to determine if further action on the particular claim is necessary as a function of specific issues associated with the particular claim.

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