Method, system and computer program product for creating software for processing an insurance claim

• US 7,856,617 B2
• Filed: 04/25/2006
• Issued: 12/21/2010
• Est. Priority Date: 04/25/2006
• Status: Active Grant

• Current Assignee: Xerox State & Local Solutions, Inc. (Conduent, Inc.)
• Original Assignee: ACS State & Local Solutions Incorporated (Conduent, Inc.)
• Inventors: Szlam, Aleksander
• Primary Examiner(s): DAS, CHAMELI
• Application Number:
  US11/412,156
• Publication Number:
  US 20070260646A1
• Time in Patent Office: 1,701 Days
• Field of Search: 717100-103, 717/106, 717/114, 717/110, 717/117, 706 45- 47, 704 1- 2, 704/4, 704 9- 10, 705/4
• US Class Current: 717/106
• CPC Class Codes: G06Q 10/087 Inventory or stock management, e.g. order filling, procurement or balancing against orders
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A method, system and computer program product are provided for creating software that can be used when processing insurance claims. In particular, the software generated is capable of recognizing and flagging certain situations or sets of conditions when they arise in an insurance claim that is being processed. These situations or sets of conditions, as well as the type of flag, or “edit,” that should be posted when each occurs, are defined in a decision table from which the software is automatically generated. A method of processing an insurance claim using the automatically generated software is also provided.

Claims

1. A method of creating software for processing an insurance claim, said method comprising:

determining one or more processes associated with each of a plurality of types of insurance claims;

determining a plurality of flags associated with each of the one or more processes for each type of insurance claim, wherein a flag associated with a process for a first type of insurance claim may differ from a flag associated with the same process for a second type of insurance claim;

creating one or more decision tables, wherein a decision table is created for each of the plurality of flags based on a separate combination of conditions defining when a respective flag should be posted to the insurance claim based at least in part on a type of the insurance claim;

providing a decision table to a software generator; and

automatically generating with a processor computer programming instructions based upon the decision table and configured to cause the respective flag to be posted based on the combinations of conditions from the decision table upon execution thereof.

2. The method of claim 1, wherein each flag comprises a code that is associated with a particular situation that is determined to have occurred based on the combination of conditions from the decision table associated with the respective flag.

3. The method of claim 2, wherein automatically generating computer programming instructions comprises automatically generating computer programming instructions configured to cause the code associated with the respective flag to be inserted into the insurance claim.

4. The method of claim 1, wherein providing the decision table to the software generator is repeated for each of the one or more decision tables, and wherein for each of the one or more decision tables, a set of computer programming instructions is automatically generated that causes the respective flag, with which the decision table is associated, to be posted based on the combination of conditions from the decision table.

5. A system for creating software for processing an insurance claim, said system comprising:

a software generator; and

a memory device comprising one or more decision tables stored therein and accessible by the software generator, wherein a decision table is defined for each of a plurality of flags based on a separate combination of conditions that must be met in order for a respective flag to be posted to the insurance claim, wherein the plurality of flags is determined to be associated with one of a plurality of processes associated with one of a plurality of types of insurance claims, and wherein the respective one of the plurality of flags is posted based at least in part on a type of the insurance claim;

wherein the software generator automatically generates computer programming instructions based upon the decision table and configured to cause the respective flag to be posted based on the combination of conditions from the decision table upon execution thereof.

6. The system of claim 5, wherein each flag comprises a code that is associated with a particular situation that is determined to have occurred when the combination of conditions from the decision table associated with the respective flag have been met.

7. The system of claim 6, wherein automatically generating computer programming instructions comprises automatically generating computer programming instructions configured to cause the code associated with the respective flag to be inserted into the insurance claim.

8. The system of claim 5, wherein for each of the one or more decision tables, the software generator automatically generates a set of computer programming instructions that causes the respective flag, with which the decision table is associated, to be posted based on the combination of conditions from the decision table.

9. A computer program product for creating software for processing an insurance claim, wherein the computer program product comprises at least one computer-readable storage medium having computer-readable program code portions stored therein, the computer-readable program code portions comprising:

a first executable portion for receiving one or more decision tables, wherein a decision table is defined for each of a plurality of flags based on a separate combination of conditions defining when a respective flag should be posted to the insurance claim, wherein the plurality of flags is determined to be associated with one of a plurality of processes associated with one of a plurality of types of insurance claims, and wherein the respective one of the plurality of flags is posted based at least in part on a type of the insurance claim; and

a second executable portion for automatically generating computer programming instructions based upon the decision table and configured to cause the respective flag to be posted based on the combination of conditions from the decision table upon execution thereof.

10. The computer program product of claim 9 further comprising:

a third executable portion for enabling a user to create the decision table.

11. The computer program product of claim 9, wherein each flag comprises a code that is associated with a particular situation that is determined to have occurred based on the combination of conditions from the decision table associated with the respective flag.

12. The computer program product of claim 11, wherein automatically generating computer programming instructions comprises automatically generating computer programming instructions configured to cause the code associated with the respective flag to be inserted into the insurance claim.

13. A method of processing an insurance claim, said method comprising:

determining which of a plurality of processes are associated with the insurance claim based at least in part on a type of the insurance claim;

determining which of a plurality of flags are associated with each of the processes associated with the insurance claim, wherein a flag associated with a process for a first type of insurance claim may differ from a flag associated with the same process for a second type of insurance claim;

accessing one or more decision tables, wherein a decision table is defined for each of the plurality of flags based on a separate combination of conditions defining when a respective flag should be posted to the insurance claim during processing of the claim for each of the associated flags;

automatically generating with a processor computer programming instructions based upon the respective decision tables and configured to cause respective flags to be posted based on the combination of conditions from the respective decision tables upon execution thereof; and

evaluating the insurance claim with the automatically generated computer programming instructions.

14. The method of claim 13, wherein the plurality of processes include validating data, verifying that a recipient is qualified for coverage, verifying that a provider is authorized to perform a service, and determining for what benefit a claimant qualifies.

15. The method of claim 13, wherein each flag comprises a code that is associated with a particular situation that is determined to have occurred based on the combination of conditions from the decision table associated with the respective flag.

16. The method of claim 15, wherein automatically generating computer programming instructions comprises automatically generating computer programming instructions configured to cause the code associated with the respective edit to be inserted into the insurance claim.