Health care patient benefits eligibility research system and methods

• US 8,433,586 B2
• Filed: 06/12/2012
• Issued: 04/30/2013
• Est. Priority Date: 02/17/2005
• Status: Active Grant

• Current Assignee: TransUnion Corporation
• Original Assignee: E-Scan Data Systems, Inc.
• Inventors: Wester, John
• Primary Examiner(s): Dunham, Jason
• Assistant Examiner(s): MISIASZEK, AMBER ALTSCHUL
• Application Number:
  US13/494,139
• Publication Number:
  US 20120253850A1
• Time in Patent Office: 322 Days
• Field of Search: 705 2- 4
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof

Abstract

The software of the present invention provides a means for creating a file of unpaid claims for a service provider. The software is used to create one or more queries to compare information in the file of claims against records in a benefit provider'"'"'s database to determine the eligibility status of the claim. A file is created containing each claim for which a matching record in the benefit provider'"'"'s database is found, and the information from that matching record. A report can be generated from the file of matching claims and benefit provider records, so the claims can be submitted for payment by the service provider.

Claims

1. A tangible, non-transitory computer program product for comparing a service provider'"'"'s medical care claims against a benefit provider'"'"'s database, the computer program product having a computer readable medium with a computer program executable by a computer embodied thereon, the computer program comprising instructions which, when executed by the computer, cause the computer to perform the following operations:

a. generating a first file of claims from the service provider, wherein said first file is organized such that data associated with at least two fields for each of the claims is formatted for comparison with the benefit provider'"'"'s database, wherein the at least two fields are different from each other;

b. executing a first query of the benefit provider'"'"'s database using data from one of said at least two fields for a claim in the first file and executing a second query of the benefit provider'"'"'s database using data from another of said at least two fields for said claim;

c. adding said claim to a second file if a record in the benefit provider'"'"'s database is responsive to said first query and said second query; and

d. generating a report indicative of one or more differences between said claim for which a responsive record was found and said responsive record, wherein dissimilar information from said claim is shown in different print than information from said responsive record.

2. The tangible computer program product of claim 1 wherein said dissimilar information from said claim shown in different print is on a separate line of said report than said information from said responsive record.

3. The tangible computer program product of claim 1 wherein said report identifies an outstanding balance eligible for reimbursement.

4. The tangible computer program product of claim 1 wherein said report identifies an incorrect service code.

5. The tangible computer program product of claim 1 wherein said report identifies a billing deadline.

6. The tangible computer program product of claim 1 wherein said report identifies an eligibility date.