Method and apparatus for repricing a reimbursement claim against a contract

• US 8,407,071 B2
• Filed: 01/18/2012
• Issued: 03/26/2013
• Est. Priority Date: 10/14/1999
• Status: Expired due to Fees

• Current Assignee: Cognizant Trizetto Software Group Incorporated (Cognizant Technology Solutions Corp.)
• Original Assignee: Trizetto Group Incorporated (Cognizant Technology Solutions Corp.)
• Inventors: Lesswing, Mark, Hoerle, Dale
• Primary Examiner(s): Frenel, Vanel
• Application Number:
  US13/352,960
• Publication Number:
  US 20120130754A1
• Time in Patent Office: 433 Days
• Field of Search: 705/4, 705/2, 705/36.R, 705/37
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/04 Trading; Exchange, e.g. stocks, commodities, derivatives or currency exchange
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A method for repricing a reimbursement claim under at least one contract is provided herein. The method may include a combination of steps such as: converting each contract into a series of contractual terms; converting a claim into a series of claim lines, containing claim codes, unit numbers and corresponding charges for the claim codes; comparing claim codes and contractual terms and identifying matches therebetween; determining any priority conditions associated to the matching contractual terms, and eliminate any matching contractual terms that are excluded by the priority conditions; calculating the reimbursement amount for the claim by determining the reimbursement charges for the non-excluded matching contractual terms; and determining and making any adjustments depending upon any discount terms for the entire reimbursement amount.

Claims

1. A computer-readable storage medium storing computer readable instructions thereon that, when executed by a computer, direct the computer to execute a method of a reimbursement platform, the method comprising:

generating a user interface providing a phrase describing a term of a contract for reimbursement, wherein said phrase includes at least one input field for receiving input from a user; and

generating information, stored to computer-readable medium, representing said term of said contract for reimbursement based at least in part on information input to said at least one input field.

2. The computer-readable storage medium of claim 1, wherein said contract for reimbursement is a contract for reimbursement by an insurer.

3. The computer-readable storage medium of claim 1, wherein said phrase includes at least one sentence.

4. The computer-readable storage medium of claim 1, wherein upon input to said at least one input field, said phrase forms at least one complete sentence.

5. The computer-readable storage medium of claim 1, wherein said at least one input field includes a drop-down menu providing a plurality of choices for selection of input to such field.

6. The computer-readable storage medium of claim 1, wherein generating information representing said term of said reimbursement contract comprises:

associating, with said term, information, stored to computer-readable medium, representing at least one qualifier having a corresponding calculation method, wherein the at least one qualifier identifies at least one condition to be satisfied by a claim for reimbursement in order to trigger the corresponding calculation method.

7. The computer-readable storage medium of claim 6, wherein said at least one input field receives information corresponding to at least one of the group consisting of:

said at least one qualifier and said calculation method.

8. The computer-readable storage medium of claim 1, the method further comprising:

generating output presenting at least one phrase describing terms of the contract for reimbursement.

9. A computer-readable storage medium storing computer readable instructions thereon that, when executed by a computer, direct the computer to execute a method of a reimbursement platform, the method comprising:

defining terms of a contract for reimbursement by an insurer; and

generating output presenting at least one phrase describing the terms of the defined contract for reimbursement.

10. The computer-readable storage medium of claim 9, wherein defining said terms of said contract comprises:

associating, with each of the terms, a qualification having a corresponding calculation method, wherein the qualification identifies when a received claim for reimbursement qualifies for reimbursement, under the term with which the qualification is associated, according to the corresponding calculation method.

11. The computer-readable storage medium of claim 9, wherein generating output comprises:

generating output presenting said at least one phrase, wherein said at least one phrase includes at least one sentence.

12. A method for generating an electronic representation of a reimbursement contract, the method comprising:

receiving, by a processor-based device, input identifying at least one term of said reimbursement contract;

for each of the at least one term, receiving, by said processor-based device, input identifying at least one qualification that specifies at least one condition to be satisfied in a claim for the claim to qualify for reimbursement according to the corresponding contract term; and

for each of the at least one qualification, receiving, by said processor-based device, input identifying a corresponding calculation method.

13. The method of claim 12, further comprising:

said processor-based device representing each of said at least one term of said reimbursement contract by storing to a computer-readable medium the corresponding at least one qualification for each of the at least one term.

14. A method for determining a reimbursement amount for a claim, comprising:

defining a reimbursement contract in computer-executable program code stored to a computer-readable medium, where said reimbursement contract includes information associating at least one term of the contract with at least one qualifier having a corresponding calculation method;

receiving into a processor-based device, information about a claim received for reimbursement; and

said processor-based device determining a reimbursement amount for the claim based at least in part on said reimbursement contract.

15. The method of claim 14, wherein said reimbursement contract comprises a contract between an insurer and a service provider.

16. The method of claim 14, wherein said claim for reimbursement is a claim by a medical service provider for reimbursement from an insurer for medical services rendered.