Data restructuring for consistent formatting

• US 10,380,320 B2
• Filed: 02/01/2013
• Issued: 08/13/2019
• Est. Priority Date: 02/03/2012
• Status: Active Grant

• Current Assignee: Experian Health, Inc. (Experian plc)
• Original Assignee: Passport Health Communications (Experian plc)
• Inventors: Farmer, Richard W., Feenstra, Donavon R.
• Primary Examiner(s): Reyes, Reginald R
• Application Number:
  US13/757,282
• Publication Number:
  US 20130204642A1
• Time in Patent Office: 2,384 Days
• Field of Search: 705 3
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

Consistently coded eligibility data is provided. Eligibility responses may be received from various payers comprising inconsistently coded eligibility benefit (EB) information provided in EB segments in various locations in the responses. A data restructuring engine may be operable to receive an eligibility response and restructure the response into a consistent format. Co-pay, co-insurance, benefit limitations, and benefit specific deductibles may be clarified by embedding coded strings in one or more message segments attached to EB segments. Service types, network indicators, place of service codes, and message text may be removed when a coded strings is created. Recoded eligibility responses may be provided to healthcare providers, providing coverage, eligibility, and benefit data in a consistent and standardized form, regardless of the payer sending the eligibility response.

Claims

1. A method of providing a recoded eligibility response as a machine-readable data structure comprising:

receiving, at a computing device that includes a restructuring engine, eligibility data in an original eligibility response;

parsing, by the restructuring engine of the computing device, the eligibility data in the original eligibility response for one or more eligibility benefit data elements and one or more message segments for free-form message text;

removing, by the restructuring engine of the computing device, the free-form message text from the one or more message segments and values of certain eligibility benefit data elements in the original eligibility response;

creating, by the restructuring engine of the computing device, the recoded eligibility response as the machine-readable data structure to include;

a message segment data structure and an eligibility benefit segment data structure, the message segment data structure comprising;

a place of service dimension,

a service type dimension,

a provider type dimension,

a relation of provider to payer dimension,

a relation of provider to patient dimension,

a reason for service dimension, and

a service category dimension;

a coded string to replace removed free-form message text;

one or more coded values for one or more of the place of service dimension, the service type dimension, the provider type dimension, the relation of provider to payer dimension, the relation of provider to patient dimension, the reason for service dimension, and the service category dimension of the message segment data structure;

an embedded tag to indicate a recoding operation for a coded string in a first message segment of the recoded eligibility response when the coded string includes inclusion information; and

an embedded tag to indicate a recoding operation for a coded string in a second message segment of the recoded eligibility response when the coded string includes exclusion information; and

sending, from the computing device, the recoded eligibility response to a requesting healthcare provider computer system.

2. The method of claim 1, further comprising parsing eligibility benefit segments and message segments in the original eligibility response for one or more of:

place of service information;

service type information;

provider type information;

relation of provider to payer information;

relation of provider to patient information;

reason for service information;

or

service category information.

3. The method of claim 2, further comprising parsing the eligibility benefit segments of the original eligibility response for code values coding one or more of:

place of service information;

service type information;

provider type information;

relation of provider to payer information;

relation of provider to patient information;

reason for service information;

or

service category information.

4. The method of claim 2, further comprising parsing the message segments of the original eligibility response for free-form message text identifying critical benefit details.

5. The method of claim 2, further comprising parsing the message segments in the original eligibility response for free-form message text identifying benefit details identified in an eligibility benefit segment and removing the free-form message text from the eligibility benefit segment.

6. The method of claim 2, further comprising:

identifying a payer sending the original eligibility response; and

looking up location information to identify possible locations in the original eligibility response to parse eligibility benefit data elements associated with the payer.

7. The method of claim 1, wherein a coded string codifies one or more of:

place of service information;

service type information;

provider type information;

relation of provider to payer information;

relation of provider to patient information;

reason for service information;

service category information;

free-form message text identifying critical benefit details;

or free-form message text identifying benefit details identified in an eligibility benefit segment.

8. The method of claim 1, further comprising recoding the original eligibility response by removing service type information, network indicators, and place of service codes from the original eligibility response.

9. The method of claim 1, further comprising inserting a separator between each dimension of the recoded eligibility response.

10. The method of claim 1, further comprising:

removing eligibility benefit code values, free-form message text identifying critical benefit details, or free-form message text identifying benefit details identified in an eligibility benefit segment that has been codified in a coded string.

11. A system to provide a recoded eligibility response as a machine-readable data structure comprising:

one or more processors;

a restructuring engine comprising executable instructions; and

a memory coupled to the one or more processors, the one or more processors to execute the executable instructions of the restructuring engine to;

receive eligibility data in an original eligibility response;

parse the eligibility data in the original eligibility response for one or more eligibility benefit data elements and one or more message segments for free-form message text

remove the free-form message text from the one or more message segments and values of certain eligibility benefit data elements in the original eligibility response;

create the recoded eligibility response as the machine-readable data structure to include;

a message segment data structure and an eligibility benefit segment data structure, the message segment data structure comprising;

a place of service dimension,

a service type dimension,

a provider type dimension,

a relation of provider to payer dimension,

a relation of provider to patient dimension,

a reason for service dimension, and

a service category dimension;

a coded string to replace removed free-form message text;

one or more coded values for one or more of the place of service dimension, the service type dimension, the provider type dimension, the relation of provider to payer dimension, the relation of provider to patient dimension, the reason for service dimension, and the service category dimension of the message segment data structure;

an embedded tag to indicate a recoding operation for a coded string in a first message segment of the recoded eligibility response when the coded string includes inclusion information; and

an embedded tag to indicate a recoding operation for a coded string in a second message segment of the recoded eligibility response when the coded string includes exclusion information; and

provide the recoded eligibility response to a requesting healthcare provider computer system.

12. The system of claim 11, further to parse eligibility benefit segments and message segments in the original eligibility response for one or more of:

place of service information;

service type information;

provider type information;

relation of provider to payer information;

relation of provider to patient information;

reason for service information;

or service category information.

13. The system of claim 12, further to parse the eligibility benefit segments for code values coding one or more of:

place of service information;

service type information;

provider type information;

relation of provider to payer information;

relation of provider to patient information;

reason for service information;

or

service category information.

14. The system of claim 12 further to parse the message segments for free-form message text identifying critical benefit details and free-form message text identifying benefit details identified in an eligibility benefit segment.

15. The system of claim 12, further to:

identify a payer sending the original eligibility response; and

look up location information to identify possible locations of eligibility benefit data elements in the original eligibility response associated with the payer.

16. The system of claim 11, wherein:

coded values codify one or more of;

place of service information;

service type information;

provider type information;

relation of provider to payer information;

relation of provider to patient information;

reason for service information;

service category information;

free-form message text identifying critical benefit details;

or free-form message text identifying benefit details identified in an eligibility benefit segment.

17. The system of claim 11, further to:

remove eligibility benefit code values, free-form message text identifying critical benefit details, or free-form message text identifying benefit details identified in an eligibility benefit segment that has been codified in a coded string; and

provide the recoded eligibility response to a healthcare provider.

18. A non-transitory computer readable medium containing computer executable instructions which, when executed by a computing device, implement a restructuring engine to perform a method of providing a recoded eligibility response as a machine-readable data structure comprising:

receiving eligibility data in an original eligibility response;

parsing, by the restructuring engine, the eligibility data in the original eligibility response for one or more eligibility benefit data elements and one or more message segments for free-form message text;

removing, by the restructuring engine, the free-form message text from the one or more message segments and values of certain eligibility benefit data elements in the original eligibility response;

creating, by the restructuring engine, the recoded eligibility response as the machine-readable data structure to include;

a message segment data structure and an eligibility benefit segment data structure, the message segment data structure comprising;

a place of service dimension,

a service type dimension,

a provider type dimension,

a relation of provider to payer dimension,

a relation of provider to patient dimension,

a reason for service dimension, and

a service category dimension;

a coded string to replace removed free-form message text;

one or more coded values for one or more of the place of service dimension, the service type dimension, the provider type dimension, the relation of provider to payer dimension, the relation of provider to patient dimension, the reason for service dimension, and the service category dimension of the message segment data structure;

an embedded tag to indicate a recoding operation for a coded string in a first message segment of the recoded eligibility response when the coded string includes inclusion information; and

an embedded tag to indicate a recoding operation for a coded string in a second message segment of the recoded eligibility response when the coded string includes exclusion information; and

providing the recoded eligibility response to a requesting healthcare provider computer system.