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System and method for rules driven insurance claim processing

  • US 9,940,675 B2
  • Filed: 10/11/2013
  • Issued: 04/10/2018
  • Est. Priority Date: 10/11/2013
  • Status: Active Grant
First Claim
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1. A system, comprising:

  • an intake computer system configured to receive, from a plurality of remote computing devices, data records corresponding to submissions received at a rate of thousands of submissions per year from the plurality of remote computing devices;

    a plurality of handler computing devices; and

    a rules driven processing engine for sequentially applying a selected combination of filters to the data records to effect an expedited processing data flow which reduces a number of data records processed according to a normal processing data flow, the rules driven processing engine interposed between the intake computer system and the plurality of handler computing devices to communicatively couple said rules driven processing engine, said intake system, and said plurality of handler computing devices, said rules driven processing engine configured to;

    receive, by a processing engine communication device from the intake computer system, one or more electronic files including the data records;

    reduce the data records to generate a first subset of reduced data records by application of a first filter rule to the data records that removes each of the data records that does not correspond to a valid policy;

    responsive to reduction of the data records and generation of the first subset of reduced data records, reduce the first subset of data records to generate a second subset of reduced data records by application of a second filter rule to the first subset of reduced data records that removes each of the data records of the first subset of reduced data records that corresponds to pre-determined legal jurisdictions;

    responsive to reduction of the first subset of reduced data records and generation of the second subset of reduced data records, reduce the second subset of reduced data records to generate a third subset of reduced data records by application of a third filter rule to the second subset of reduced data records that removes each of the data records of the second subset of reduced data records that corresponds to a pre-determined injury type, wherein the third subset of reduced data records comprises a final subset of reduced data records;

    automatically transmit the data records removed by sequential application of the selected combination of filters to a normal workflow module of a workflow management system configured to assign each of the removed data records to a handler based upon a complexity of a claim corresponding to the data record and handler workload, and transmit an electronic file corresponding to each of the removed data records to one of the plurality of handler computing devices, each corresponding to one of the assigned handlers, wherein the data records removed by sequential application of the selected combination of filters comprise a reduced subset of the data records received from the intake computer system;

    automatically transmit the final subset of reduced data records not removed by sequential application of the selected combination of filters to an expedited workflow module of the workflow management system, the expedited workflow module configured to;

    sort data records of the final subset of reduced data records into a first expedited data record subset including each of the data records of the final subset of reduced data records which has a corresponding payment value below a pre-determined threshold and a second expedited data record subset including each of the data records of the final subset of reduced data records which has a corresponding payment value above the pre-determined threshold;

    generate a payment for each of the data records of the first expedited data record subset, without each such data record being transmitted to one of the plurality of handler computing devices for processing by a handler according to the normal workflow module of the workflow management system; and

    transmit each of the data records of the second expedited data record subset to one of the plurality of handler computing devices for processing by a handler who specializes in processing of data records transmitted to the expedited workflow module; and

    output, to a team leader computing device, a display including data indicative of the final subset of reduced data records.

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