Method and apparatus for repricing a reimbursement claim against a contract

• US 8,666,787 B2
• Filed: 12/10/2012
• Issued: 03/04/2014
• 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 Corporation (Cognizant Technology Solutions Corp.)
• Inventors: Lesswing, Mark, Hoerle, Dale
• Primary Examiner(s): SEOH, MINNAH L
• Application Number:
  US13/709,141
• Publication Number:
  US 20130144648A1
• Time in Patent Office: 449 Days
• Field of Search: 705 2- 3, 705/4, 705/36.R, 705/37, 705/204
• 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 implemented method of repricing an electronically received reimbursement claim under at least one contract comprising:

converting by the computer each of the at least one contracts into a plurality of terms and a contract identifier code, each of the plurality of terms, of the plurality of terms, containing qualification codes and calculation codes;

converting by the computer the reimbursement claim into a series of claim lines, each claim line containing a claim code;

comparing by the computer each claim code, of the series of claim lines, against each qualification code, of the plurality of terms for each at least one contract and when a claim code, of a claim line, is substantially equal to a qualification code, of a term, identifying said term as a matching term associated to said claim line; and

determining by the computer a reimbursement amount under each at least one contract for the claim by processing the calculation codes of the matching terms.

2. The computer implemented method of claim 1, further comprising:

determining if any matching terms should be excluded and eliminating any excluded matching terms prior to determining the reimbursement amount.

3. The computer implemented method of claim 2, wherein the step of determining the reimbursement amount includes:

determining by the computer a reimbursement charge for each claim line associated to a non-eliminated matching term; and

adding by the computer the reimbursement charges for said claim lines, whereby the reimbursement amount for the claim is the addition of the reimbursement charges.

4. The computer implemented method of claim 1 wherein converting the claim further includes associating by the computer the claim to a claim identifier code.

5. The computer implemented method of claim 4 further including:

comparing by the computer the claim identifier code, against the contract identifier code for each of the at least one contracts, and when the claim identifier code is substantially equal to a contract identifier code, of at least one contract, identifying said at least one contract as a governing contract, wherein the repricing of said claim is repriced only against said governing contract.

6. The computer implemented method of claim 5 wherein the step of repricing the claim against said governing contract further includes:

when at least two contracts are identified as governing contracts, repricing by the computer said claim against each governing contract creating a list of governing reimbursement amounts.

7. The computer implemented method of claim 6 further comprising:

determining by the computer a lowest governing reimbursement amount from the list of governing reimbursement amounts, wherein the lowest governing reimbursement amount is the reimbursement amount of said claim.

8. The computer implemented method of claim 3 further comprising:

storing by the computer the reimbursement amount of a claim and storing said claim as a repriced claim.

9. The computer implemented method of claim 8 wherein prior to determining the reimbursement amount for a claim the method including:

comparing the claim identifier code, of said claim, against the claim identifier codes, of all stored repriced claims;

when the claim identifier code, of said claim is substantially equal to the claim identifier codes, of a stored repriced claim, combining the claim lines of said claim with the claim line of said repriced claim creating a bundled claim;

determining by the computer the reimbursement amount of the bundled claim, instead of determining the reimbursement amount of said claim; and

rewriting the reimbursement amount of the stored repriced claim with the reimbursement amount of the bundled claim and rewriting the stored claim with the bundled claim.

10. The computer implemented method of claim 7 further comprising:

storing by the computer the reimbursement amount of a claim and storing said claim as a repriced claim.

11. The computer implemented method of claim 10 wherein prior to determining the reimbursement amount for a claim the method including:

comparing the claim identifier code, of said claim, against the claim identifier codes, of all stored repriced claims;

when the claim identifier code, of said claim is substantially equal to the claim identifier codes, of a stored repriced claim, combining the claim lines of said claim with the claim line of said repriced claim creating a bundled claim;

determining by the computer the reimbursement amount of the bundled claim, instead of determining the reimbursement amount of said claim; and

rewriting the reimbursement amount of the stored repriced claim with the reimbursement amount of the bundled claim and rewriting the stored claim with the bundled claim.

12. A computer implemented method for repricing a reimbursement claim under at least one contract, (1) each claim containing at least one claim line, each claim line being defined by at least a claim identifier code and a corresponding charge, and (2) each at least one contract containing at least one contractual term, each contractual term being defined by at least one qualification code and at least one calculation code, the method for repricing comprising:

converting by the computer each of the at least one contracts into at least one contractual term including at least one qualification code and at least one calculation code and a contract identifier code;

converting by the computer the reimbursement claim into the at least one claim line, each at least one claim line containing a claim identifier code and a corresponding charge;

comparing by the computer each claim identifier code, of the claim, against each qualification code, of each contractual term, of each of the at least one contracts;

when a qualification code, of a contractual term, is satisfied by a claim identifier code, of a claim line, identifying said contractual term as a matching contractual term associated to said claim line, and creating by the computer a list of all matching contractual terms under each of the at least one contracts;

determining by the computer a reimbursement charge for each claim line associated to a matching contractual term, and adding the reimbursement charges for said claim lines, wherein the reimbursement amount for the claim is the addition of said reimbursement charges in accordance with each of the at least one contracts;

determining by the computer which of the at least one contracts governs the reimbursement claim; and

repricing by the computer the reimbursement claim in accordance with the governing at least one contract.

13. The computer implemented method of claim 12 further comprising:

determining by the computer if any matching contractual terms should be excluded and excluding any reimbursement charges associated therewith from the added reimbursement amount.

14. The computer implemented method of claim 12 further comprising:

determining by the computer if any single matching contractual term should reprice the reimbursement claim, eliminating all other matching contractual terms and repricing by the computer the reimbursement claim in accordance with the single matching contractual term.

15. The computer implemented method of claim 12 wherein the step of determining by the computer which of the at least one contracts governs the reimbursement claim includes:

comparing a claim identifier code associated with each reimbursement claim against a contract identifier code associated with each of the at least one contracts, wherein when the claim identifier code is substantially equal to a contract identifier code of an at least one contract, said contract is determined to be the governing contract.

16. The computer implemented method of claim 15 wherein the step repricing by the computer the reimbursement claim in accordance with the governing at least one contract includes:

when at least two contracts are identified as governing contracts, repricing said claim against each governing contract creating a list of governing reimbursement amounts, wherein the reimbursement amount of said claim is the lowest governing reimbursement amount.

17. The computer implemented method of claim 12 further including:

storing by the computer the reimbursement amount of a claim and storing said claim as a repriced claim.

18. The computer implemented method of claim 17 wherein prior to determining the reimbursement amount for a claim the method including:

comparing the claim identifier code, of said claim, against the claim identifier codes, of all stored repriced claims;

when the claim identifier code, of said claim is substantially equal to the claim identifier codes, of a stored repriced claim, combining the claim lines of said claim with the claim line of said repriced claim creating a bundled claim;

determining by the computer the reimbursement amount of the bundled claim, instead of determining the reimbursement amount of said claim; and

rewriting the reimbursement amount of the stored repriced claim with the reimbursement amount of the bundled claim and rewriting the stored claim with the bundled claim.

19. The computer implemented method of claim 16 further including:

storing by the computer the reimbursement amount of a claim and storing said claim as a repriced claim.

20. The computer implemented method of claim 17 wherein prior to determining the reimbursement amount for a claim the method including:

comparing the claim identifier code, of said claim, against the claim identifier codes, of all stored repriced claims;

when the claim identifier code, of said claim is substantially equal to the claim identifier codes, of a stored repriced claim, combining the claim lines of said claim with the claim line of said repriced claim creating a bundled claim;

determining by the computer the reimbursement amount of the bundled claim, instead of determining the reimbursement amount of said claim; and

rewriting the reimbursement amount of the stored repriced claim with the reimbursement amount of the bundled claim and rewriting the stored claim with the bundled claim.