System and method of processing a health insurance claim
First Claim
1. A method of adjudicating a health insurance transaction, the method including:
- receiving transaction data transmitted from a third party computer via an open communication channel with the third party computer, the transaction data relating to a health insurance transaction, the transaction data including at least a unique identifier for a beneficiary of a health insurance plan to whom the health insurance transaction relates and details of a transaction that is being requested to be adjudicated;
executing instructions by a computer processor to adjudicate the transaction while the communication channel remains open by applying rules to fully adjudicate the transaction; and
responding while the communication channel remains open whether the transaction will be paid or will not be paid or will be partially paid.
1 Assignment
0 Petitions
Accused Products
Abstract
A system and method of processing a health insurance claim are provided. According to the method, transaction data is received that has been transmitted from a third party computer via an open communication channel with the third party computer. The transaction data relates to a health insurance transaction and includes at least a unique identifier for a beneficiary of a health insurance plan to whom the health insurance transaction relates and details of a transaction that is being requested to be processed. The transaction is processed while the communication channel remains open to ascertain if the transaction is an allowable transaction. In response to the transaction submitted, a message is transmitted via the open communication channel to the third party computer wherein the message indicates that the transaction has been processed and that the transaction is an allowable transaction with or without patient collection or that the transaction is not an allowable transaction. The system and method allow for multiple rules to be created for unique sets of circumstances using multiple or singular inputs across multiple health insurance plans using a single system.
34 Citations
35 Claims
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1. A method of adjudicating a health insurance transaction, the method including:
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receiving transaction data transmitted from a third party computer via an open communication channel with the third party computer, the transaction data relating to a health insurance transaction, the transaction data including at least a unique identifier for a beneficiary of a health insurance plan to whom the health insurance transaction relates and details of a transaction that is being requested to be adjudicated; executing instructions by a computer processor to adjudicate the transaction while the communication channel remains open by applying rules to fully adjudicate the transaction; and responding while the communication channel remains open whether the transaction will be paid or will not be paid or will be partially paid. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15)
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16. A system for adjudicating a health insurance transaction, the system including:
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a data receiving module for receiving transaction data transmitted from a third party computer via an open communication channel, the transaction data relating to a health insurance transaction, the transaction data including at least a unique identifier for a beneficiary of a health insurance plan to whom the health insurance transaction relates and details of a transaction that is being requested to be adjudicated; a processor for processing the transaction while the communication channel remains open by applying rules to fully adjudicate the transaction; responding while the communication channel remains open whether the transaction will be paid or will not be paid or will be partially paid. - View Dependent Claims (17, 18, 19, 20, 21, 22, 23, 24, 25, 26)
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27. A method of adjudicating a transaction, the method including:
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receiving transaction data transmitted from a third party computer via an open communication channel with the third party computer, the transaction data including at least a unique identifier for a beneficiary of the transaction; executing instructions by a computer processor to adjudicate the transaction while the communication channel remains open by applying rules to fully adjudicate the transaction; and responding while the communication channel remains open whether the transaction will be paid or will not be paid or will be partially paid. - View Dependent Claims (28, 29, 30, 31, 32, 33, 34, 35)
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Specification