System and method for managing the exchange of information between healthcare systems

• US 7,778,844 B2
• Filed: 08/04/2005
• Issued: 08/17/2010
• Est. Priority Date: 08/04/2005
• Status: Expired due to Fees

• Current Assignee: IDX Investment Corporation (General Electric Company)
• Original Assignee: IDX Investment Corporation (General Electric Company)
• Inventors: Harold, Monique, Ammer, Mary J., Khoury, Esther, Belcher, Deborah J.
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): Pauls; John A
• Application Number:
  US11/196,875
• Publication Number:
  US 20070033066A1
• Time in Patent Office: 1,839 Days
• Field of Search: 705/2, 705/3, 705/4
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: G16H 70/60 relating to pathologies

Abstract

An improved system for managing the exchange of information between healthcare systems. The system automatedly processes a healthcare data inquiry to produce a response readable by a requestor. This response may include content data, such as claims attachment data requested in a healthcare claims attachment inquiry. The content data may reside on data stores which the system must access in order to retrieve the necessary content data. The system may use criteria for automatedly interpreting the healthcare data inquiry.

Claims

1. A system for handling one or more healthcare data inquiry requiring content data, the system comprising:

a processing module operating on a processor that is configured to;

receives a healthcare data inquiry from a requestor in a first standard healthcare data format, said healthcare data inquiry including at least one request for content data

automatically determines at least one data element of the requested content data;

determine if the at least one data element is available at a data store, and if the at least one data element is available, acquire the at least one data element from the data store;

a worklist module operating on the processor and in communication with said processing module, said worklist module configured to;

store one or more work items created by the processing module, when the at least one data element is available, wherein the one or more work items comprise an identification of the unavailable data element and a location of the unavailable data element;

present the one or more work items on a graphical display; and

receive from a user at least one data element identified by the one or more presented work items; and

a response module operating on the processor and in communication with said processing module and said worklist module, the response module configured to;

receive at least one acquired data element from the processing module; and

receive at least one retrieved data element from the worklist module;

format the acquired data element and the retrieved data element into a second standard healthcare data format; and

send the formatted data elements to the requester.

2. A system according to claim 1, wherein said worklist module develops work items that include said at least one request for one or more content data.

3. A system according to claim 2, wherein said response module sends said data elements in response to a command generated by a user in response to said work items.

4. A system for responding to a healthcare data inquiry for content data from one or more data stores having one or more data elements stored therein, the system comprising:

a rules module operating on a processor and that comprises one or more criteria for interpreting content data requests;

a processing module operating on the processor and in communication with said rules module, said processing module configured to;

receives a healthcare data inquiry, including a request for content data;

compares the received request to said one or more criteria to identify at least one data element required by the requested content data;

retrieves the at least one data element from one or more data stores comprising the at least one data element;

wherein, if a data element is not available from the data stores, the processing module identifies a locally unavailable data element and a location for retrieval of the locally unavailable data element;

cause an identification of the locally unavailable data element to be presented to a user; and

receive the locally unavailable data element from the user;

a response module operating on the processor and in communication with said processing module, said response module configured to sends the at least one data element retrieved from the data stores and the locally unavailable data element to a requester in a standard healthcare data inquiry format; and

a statistics module operating on the computer processor and in communication with the processing module, the statistics module configured to collect statistics associated with the received healthcare data inquiries.

5. A system according to claim 4, further comprising a worklist module operating on the processor and working with the processing module, the worklist module configured to:

creates one or more work items that identify the locally unavailable data element and the location; and

presents the work item to a user for retrieval of the locally unavailable data element.

6. A system according to claim 4, wherein said healthcare data inquiry is a healthcare claims attachment inquiry and said rules module, said processing module and said response module are adapted to handle said healthcare claims attachment inquiry.

7. A system according to claim 4, wherein said healthcare data inquiry is a healthcare authorization attachment inquiry and said rules module, said processing module and said response module are adapted to handle said healthcare authorization attachment inquiry.

8. A system for automatically retrieving content data for a healthcare claim from one or more data stores having one or more data elements stored therein, the system comprising:

a receiver module operating on a computer processor, the receiver module configured to receives a healthcare data inquiry from a requestor, said healthcare data inquiry including a request for content data;

a rules module operating on the computer processor, the rules module comprising one or more criteria for interpreting various healthcare data inquiries,

a comparison module operating on the computer processor and in communication with said receiver module and said rules module, said comparison module configured to;

compares said healthcare data inquiry to said rules to identify one or more data elements associated with said content data; and

determine which of the one or more data stores includes said one or more data elements;

an acquisition module operating on the computer processor in communication with said comparison module and the one or more data stores, said acquisition module configured to acquire said identified one or more data elements;

a worklist module operating on the computer processor, the worklist module configured to;

creates a work item including an identification and a location of a data element that was not retrieved by the acquisition module from the one or more data stores;

cause the work item to be presented to a user; and

receive a retrieved data element from the user;

a response module operating on the computer processor in communication with said acquisition module and said worklist module, said response module configured to;

receive the acquired data elements from the acquisition module;

receive the retrieved data elements from the worklist module; and

send said one or more data elements to said requestor in a standard format; and

a statistics module operating on the computer processor and in communication with the processing module, said statistics module configured to collects statistics associated with the received healthcare data inquiries.

9. A system according to claim 8, further comprising a notification module operating on the computer processor in communication with said receiver module, wherein said notification module generates a billing system notification.

10. A system according to claim 8, further comprising a tracking module operating on the computer processor in communication with said receiver module and said comparison module, where said tracking module generates a tracking record associated with said healthcare data inquiry.

11. A system according to claim 8, further comprising an update module operating on the computer processor that updates said one or more rules with information learned during an acquisition of a particular data element.

12. A system according to claim 8, further comprising a packaging module operating on the computer processor in communication with said response module, wherein said packaging module formats the retrieved one or more data elements into a standard healthcare data format and bundles a plurality of said one or more data elements for delivery to said requester.

13. A system according to claim 8, further comprising an intelligent learning module operating on the computer processor in communication with said statistics module, the intelligent learning module analyzes said statistics and modifies the one or more criteria of the rules module, in response to the analyzed statistics.

14. A system according to claim 8, wherein said standard format includes an X12N 275 healthcare claims standard.

15. A system according to claim 8, wherein said healthcare data inquiry is a healthcare authorization attachment inquiry.

16. A method of responding to a healthcare data inquiry, the method comprising:

receiving with a processor a healthcare data inquiry from a requester, said healthcare data inquiry including a request for content data;

automatedly determining with the processor at least one data element of the requested content data by applying at least one criteria including one or more rules for interpreting a request for content data;

automatedly determining with the processor a location of the at least one available data element from a plurality of data stores;

automatically determining with the processor, at least one unavailable data element, not found in the plurality of data stores;

presenting an identification of the unavailable data element;

receiving, with the processor, the at least one unavailable data element, retrieved from outside of the plurality of data stores;

retrieving with the processor said the at least one available data element from the plurality of data stores;

formatting with the processor the at least one available data element and at least one unavailable data element into a claims attachment in a predetermined format;

transmitting said claims attachment to said requestor;

monitoring, with the processor, statistics regarding a plurality of healthcare data inquiries from the requester;

analyzing the statistics with the processor; and

modifying the one or more rules based on the analyzed statistics.

17. A method according to claim 16, wherein said receiving step involves receiving said request from a third party payer.

18. A method according to claim 16, wherein said receiving step involves receiving said request from a claims financial system.

19. A method according to claim 16, wherein said receiving step involves receiving said request from an Electronic Data Interchange (EDI) system.

20. A method according to claim 16, further comprising creating with the processor a tracking record associated with said healthcare data inquiry.

21. A method according to claim 16, further comprising generating with the processor a billing system notification, said notification indicating receipt of said healthcare data inquiry.

22. A method according to claim 16, further comprising:

storing said healthcare data inquiry in a first database; and

retrieving said healthcare data inquiry from said first database.

23. A method according to claim 16, further comprising packaging a plurality of the at least one data element for delivery to said requestor.

24. A method according to claim 16, wherein said predetermined format includes an X12N 275 healthcare claims standard.

25. A non-transitory computer readable medium having computer-executable instructions for implementing a method of managing the exchange of information between healthcare systems, the instructions comprising:

a first set of instructions for receiving a healthcare data inquiry from a requestor, said healthcare data inquiry including a request for content data;

a second set of instructions for automatedly determining one or more data elements in the requested content data using a criteria including one or more rules for interpreting a variety of content data;

a third set of instructions for automatedly determining a location of said one or more data elements amongst one or more data stores;

a fourth set of instructions for retrieving said one or more data elements from said one or more data stores;

a fifth set of instructions for formatting said one or more data elements into a claims attachment in a predetermined format;

a sixth set of instructions for transmitting said claims attachment to said requestor; and

a seventh set of instructions for monitoring a plurality of received healthcare data inquiries and modifying the one or more rules in response to the monitored healthcare data inquiries.

26. A computer readable medium according to claim 25, said instructions including an eighth set of instructions for creating a tracking record associated with said healthcare data inquiry.

27. A computer readable medium according to claim 25, said instructions including an eighth set of instructions for generating a billing system notification, said notification indicating receipt of said healthcare data inquiry.

28. A computer readable medium according to claim 25, said instructions including:

an eighth set of instructions for storing said healthcare data inquiry in a first database; and

a ninth set of instructions for retrieving said healthcare data inquiry from said first database.

29. A computer readable medium according to claim 25, said instructions further comprising an eighth set of instructions for packaging a plurality of said one or more data elements for delivery to said requestor.