Systems to assist in the creation, transmission, and processing of health insurance claims

• US 9,619,841 B2
• Filed: 11/25/2014
• Issued: 04/11/2017
• Est. Priority Date: 03/28/1996
• Status: Expired due to Fees

• Current Assignee: Integrated Claims Systems LLC
• Original Assignee: Integrated Claims Systems LLC
• Inventors: DiRienzo, Andrew L.
• Primary Examiner(s): NGUYEN, HIEP VAN
• Application Number:
  US14/553,201
• Publication Number:
  US 20150088560A1
• Time in Patent Office: 868 Days
• Field of Search: 705 3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Systems to assist in the creation, transmission, and processing of health insurance claims. Computer-implemented methods that enable the receiving of, storing of, and granting access to data in such systems.

Claims

1. A system comprising:

a first computer system having software for generation of structured files comprising respective subsets of a plurality of identifiable fields,

wherein each identifiable field of the subsets of the plurality of identifiable fields comprises data that uniquely identifies that identifiable field; and

wherein at least one identifiable field of the respective subset of the plurality of identifiable fields of a generated structured file further comprises content data;

a second computer system;

a third computer system; and

a fourth computer system having software for processing structured files generated by the first computer system, with each of the structured files to be processed comprising its respective subset of the plurality of identifiable fields;

wherein each computer system comprises at least one computer;

wherein the software of the fourth computer system is coordinated with the software of the first computer system so that each knows the data that uniquely identifies each of the identifiable fields of the plurality of identifiable fields of the structured files generated by the software of the first computer;

wherein the first computer system is configured to receive, through input, first content data and second content data;

wherein the first content data comprises at least one image, and

wherein the second content data

comprises ASCII text data, and

comprises no image data;

wherein the first computer system is configured to, in response in part to receipt of the first content data and the second content data, both

generate a first structured file using its software, wherein the first structured file

comprises a first subset of the plurality of identifiable fields;

wherein each identifiable field of the first subset of the plurality of identifiable fields

 

comprises respective data that uniquely identifies that identifiable field;

wherein at least one of the identifiable fields of the first subset of the plurality of identifiable fields

 

further comprises the at least one image as content data,

wherein at least one other of the identifiable fields of the first subset of the plurality of identifiable fields

 

further comprises cross-referencing data as content data, and

transmit the first structured file to the second computer system;

wherein the first computer system is configured to, in response in part to receipt of the first content data and the second content data, both

generate a second structured file using its software, wherein the second structured file

comprises a second subset of the plurality of identifiable fields;

wherein each identifiable field of the second subset of the plurality of identifiable fields

 

comprises respective data that uniquely identifies that identifiable field;

wherein a plurality of the identifiable fields of the second subset of the plurality of identifiable fields

 

further comprise respective portions of the ASCII text data of the second content data,

wherein at least one other of the identifiable fields of the second subset of the plurality of identifiable fields

 

further comprises the cross-referencing data as content data, and

wherein the second structured file does not contain image data; and

transmit the second structured file to the third computer system;

wherein the fourth computer system is configured to access the second structured file at the third computer system;

wherein the fourth computer system is configured to access at least one of the identifiable fields of the first subset of the plurality of identifiable fields comprising the at least one image as content data from the first structured file at the second computer system by using the cross-referencing data in the second structured file;

wherein the fourth computer system is configured to process the second structured file using its software, at least in part, by generating a third structured file using its software, the third structured file comprising a third subset of the plurality of identifiable fields,

wherein each identifiable field of the third subset of the plurality of identifiable fields

comprises respective data that uniquely identifies that identifiable field; and

further comprises respective content data;

wherein the fourth computer system

uses the data uniquely identifying each of the identifiable fields of the second subset of the plurality of identifiable fields in the second structured file to identify at least one particular identifiable field in the second structured file,

uses the data uniquely identifying each of the identifiable fields of the third subset of the plurality of identifiable fields in the third structured file to identify at least one particular identifiable field in the third structured file that corresponds to the at least one particular identifiable field identified in the second structured file, and

uses the content data in the identified at least one particular identifiable field in the second structured file to generate content data for the corresponding at least one particular identifiable field in the third structured file.

2. The system of claim 1, wherein the second structured file comprises a form and the first structured file comprises an image attachment to the form.

3. The system of claim 2, further comprising:

wherein the form is one selected from a group consisting of a health-insurance claim form, a property-casualty-insurance claim form, and a law-enforcement form;

wherein the health-insurance claim form is one selected from the group consisting of a dental-insurance prior-approval claim form, a dental-insurance claim form, a medical-insurance prior-approval claim form, a medical-insurance claim form; and

wherein the image attachment to the form is one selected from a group consisting of a dental-insurance-claim image attachment, a medical-insurance-claim image attachment, and a property/casualty-insurance-claim image attachment.

4. The system of claim 1, wherein

the first content data comprises health-care data;

wherein the health-care data is one selected from the group consisting of medical data and dental data;

the second content data comprises health-insurance claim data;

wherein the health-insurance claim data is one selected from the group consisting of dental-insurance prior-approval claim data, dental-insurance claim data;

medical-insurance prior-approval claim data, and medical-insurance claim data; and

the health-insurance claim data and health-care data are related to a particular health care encounter between a patient and a health care provider.

5. The system of claim 1, wherein the first content data comprises at least one item selected from a group consisting of a dental X-ray, an Explanation Of Benefits (EOB), an X-ray, a CT, an MM, an EKG, an EEG, a recording, a digitized video signal, a transcription of Operating Room Notes, pictures, graphs, sound recordings, and ASCII text.

6. The system of claim 1, wherein the second content data comprises at least one item selected from a group consisting of patient name, patient identification, patient social security number, provider name, provider address, provider identification number, examination and treatment record, and insurance company name.

7. The system of claim 1, wherein the fourth computer system comprises first and second computer subsystems.

8. The system of claim 7, wherein the first computer subsystem contains at least a claims management computer and the second computer subsystem contains at least a buffer computer.

9. The system of claim 8, wherein the buffer computer is used to access and display the first structured file at the second computer, and wherein the claims manager computer is used to access and display the second structured file at the third computer.

10. The system of claim 7, wherein the first and second computer subsystems are networked together.

11. The system of claim 7, wherein the first and second computer subsystems are not networked together.

12. The system of claim 1, wherein the first computer system is located at a dental health care provider'"'"'s office.

13. The system of claim 1, wherein when the second structured file reaches the fourth computer system, the fourth computer system is configured such that content data from at least one of the identifiable fields of the second structured file is transferred directly into a correlated field in the software of the fourth computer system without manual reentry.

14. The system of claim 1, wherein the second computer is an online computer.

15. The system of claim 1, wherein the second computer is at least one of a value added service computer and a computer comprising a data bank.

16. The system of claim 15, wherein the value added service acts as an online archiving service for patients'"'"' health-care records.

17. The system of claim 1, wherein the third computer is an insurance claims clearinghouse.

18. The system of claim 1, wherein the third structured file is an Explanation Of Benefits (EOB).

19. A computer-implemented method that enables intermediation of structured files among mutually communicating computer systems, the method comprising:

coordinating software on an intermediate computer system, software on a first computer system and software on a second computer system,

wherein communications among the three computer systems comprises transfer of structured files generated by the coordinated software,

wherein each of the structured files is

comprised of content data in identifiable fields selected from a plurality of identifiable fields, and

comprised of, for each identifiable field of such structured files, data that uniquely identifies that identifiable field, and

wherein the software of the intermediate computer system is coordinated with the software of each of the first computer system and the second computer system such that the software of each of the three computer systems knows the data that uniquely identifies each identifiable field of the plurality of identifiable fields of the structured files;

receiving, at the intermediate computer system, a first structured file from the first computer system;

wherein the first structured file comprises at least one identifiable field of the plurality of identifiable fields having image data as its respective content data, and at least one other identifiable field of the plurality of identifiable fields having ASCII text data as its respective content data;

storing, by the intermediate computer system,

a plurality of the identifiable fields of the received first structured file and the content data in those identifiable fields and, for each identifiable field stored, storing the data that uniquely identifies that identifiable field;

storing, by the intermediate computer system,

cross-referencing data that

corresponds to the plurality of the identifiable fields of the first structured file stored by the intermediate computer system;

receiving, at the intermediate computer system, a communication from the second computer system requesting identifiable fields,

wherein the electronic communication comprises the cross-referencing data; and

wherein the requested identifiable fields comprise at least one identifiable field of the stored identifiable fields of the intermediate computer system having image data as its respective content data;

determining, using the software of the intermediate computer system, the stored identifiable fields of the intermediate computer system that correspond to both the cross-referencing data and the requested identifiable fields;

transmitting, to the second computer system, the requested identifiable fields of the stored identifiable fields of the intermediate computer system that were determined to correspond to the cross-referencing data and the content data in those transmitted identifiable fields, and for each identifiable field transmitted, transmitting the data that uniquely identifies that identifiable field,

wherein the identifiable fields that are transmitted are determined by using the data that uniquely identifies each of the identifiable fields; and

wherein the intermediate computer system comprises at least one computer.

20. The method of claim 19, wherein the content data of the first structured file comprises a patient'"'"'s health-care data.

21. The method of claim 20, wherein the patient'"'"'s health-care data is from a particular health care encounter between a patient and a health care provider.

22. The method of claim 20, wherein the patient'"'"'s health-care data comprises at least one of medical data, dental data, and health-insurance-claim attachment data.

23. The method of claim 20, wherein the patient'"'"'s health-care data comprises at least one item selected from a group consisting of a dental X-ray, an X-ray, a CT, an MRI, an EKG, an EEG, a recording, a digitized video signal, a transcription of Operating Room Notes, pictures, graphs, sound recordings and ASCII text.

24. The method of claim 19, wherein:

the intermediate computer system is one of a value added service computer and a national dental data bank computer;

the first computer system is a health care provider'"'"'s computer; and

the second computer system is one of a health care payer'"'"'s computer and a health care provider'"'"'s computer.

25. The method of claim 19, wherein the intermediate computer is an online computer that is accessible online by the first and second computer systems.