Method and system for processing health care electronic data transactions

• US 5,930,759 A
• Filed: 04/30/1996
• Issued: 07/27/1999
• Est. Priority Date: 04/30/1996
• Status: Expired due to Term

• Current Assignee: Optimum, Inc., Symbol Technologies, LLC (Zebra Technologies Corporation)
• Original Assignee: Optimum, Inc., Symbol Technologies, Inc. (Zebra Technologies Corporation)
• Inventors: Moore, James G., Jones, Wayne E.
• Primary Examiner(s): MacDonald, Allen R.
• Assistant Examiner(s): Kanof, Pedro R.
• Application Number:
  US08/641,173
• Time in Patent Office: 1,183 Days
• Field of Search: 705/2, 705/3, 705/4, 705/5
• US Class Current: 705/2
• CPC Class Codes: B42D 15/00 Printed matter of special format or style not otherwise provided for
• CPC Class Codes: G06K 19/06037 multi-dimensional coding
• CPC Class Codes: G06K 2019/06253 for a specific application
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/102 Bill distribution or payments
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G06Q 99/00 Subject matter not provided for in other groups of this subclass
• CPC Class Codes: G16H 40/67 for remote operation

Abstract

A system or network for assembling, filing and processing health care data transactions and insurance claims made by patients pursuant to health care policies issued to the patients by insurance companies or other carriers for service provided to the patients at health care facilities. The network comprises a multitude of participating patients, a multitude of health care facilities, and a plurality of insurance companies or other carriers. Each of the patients has a personal data file including a set of patient related data encoded in a machine readable format, and each of the health care facilities has a telecommunications unit and a file reader to read the data on the personal data files and to transmit the patient related data to the telecommunications unit at the facility. The network further includes a central claims processing unit connected to the telecommunications units of the health care facilities to receive the electronic claim forms from those facilities and to adjudicate those claims.

Claims

1. A system for filing health care claims electronically when health care services are provided to a patient by a service provider and paid or recorded by a third party payor upon the receipt of a health care claim, said system comprising:

(a) a personal data card to be carried by the patient, said card bearing human readable indicia identifying the patient, and a machine readable data file, said data file including a two dimensional pattern of marks wherein the encoded marks together include a plurality of information words, including patient identification, third party insurer identification, and entitlement and benefit information relation to the relationship between the patient and the third party payor;

(b) a reader for scanning the machine readable data file and decoding said two dimensional pattern of marks into a plurality of separated patient digital fields and insurer digital fields, each of said fields enabling one or more information words to be decoded therefrom;

(c) means for entering a plurality of service provider digital fields entered by said service provider, said service provider digital fields representing service provided to said patient,

(d) a data processing means for receiving said separated patient digital fields and said insurer digital fields from said reader, and said plurality of service provider digital fields entered by said service provider, said data processing means assembling said fields to form a health care claim to be presented to said payor for payment thereof on behalf of the patient;

(e) data memory means for storing one or more health care insurance claims for services rendered to one or more patients by said service provider as digital claims;

(f) data communication means for transmitting one or more of the digital claims from said service provider to said payor or clearing house via a common carrier.

2. A system for filing health care claims electronically as claimed in claim 1, wherein said means for entering a plurality of service provider digital fields includes a keyboard.

3. A system for filing health care claims electronically as claimed in claim 1, wherein said means for entering a plurality of service provider digital fields includes a Graphical User Interface and a touchscreen.

4. A system for filing health care claims electronically as claimed in claim 3, wherein said means for entering a plurality of service provider digital fields also includes a keyboard.

5. A system for filing health care claims electronically as claimed in claim 1, wherein said reader includes a scanner for scanning said two dimensional pattern of marks and generating a scan signal, and a decoder for converting said scan signal into said separate patient digital fields and converting said information words into ASCII characters within said fields.

6. A system for filing health care claims electronically as claimed in claim 4, wherein said system further includes a smart telephone, said telephone including said touchscreen, said keyboard, said data processing means, said data memory means and a modem for converting said digital claims into modulated signals for telephone transmission to said insurer or payor.

7. A system for filing health care claims electronically as claimed in claim 1, wherein said system further includes a common digital claim format to enable multiple claims to different payors to be filed with a medical claims clearing house in a single data transmission.

8. A system for filing health care claims electronically as claimed in claim 1, wherein said system further includes a printer for printing copies of said machine readable data file on a removable label that may be attached to a patient file maintained by said service provider for said patient.

9. A system as claimed in claim 1, further comprising:

means for refiling or correcting and refiling a health care transaction by scanning the machine readable code produced by the printer at the time of the original electronic filing.

10. A system as claimed in claim 1, further comprising:

means for providing health care facilities with electronic patient and other data by downloading an electronically printed bar code after receiving from the provider the minimal identification data of the policy holder.

11. A system as claimed in claim 1, further comprising:

means for transferring data entered into the telecommunications device into a personal computer to populate the personal computer practice management system.

12. A system for filing health care claims electronically as claimed in claim 1, wherein said data file includes a telephone number for said payor encoded therein to enable said data processing means and said data communication means to automatically connect the service provider with the payor via a common carrier to verify a benefit or entitlement prior to providing service to said patient.

13. A health care data card for completing health care claims to be filed electronically when health care services are provided to a patient by a service provider and paid by a third party payor upon the receipt of a health care claim, said data card comprising a health care data card issued by the third party insurer and carried by the patient, said card bearing human readable indicia identifying the patient, the service provider, and a machine readable data file, said data file including at least two adjacent codewords, each codeword represented by a pattern of marks wherein the codewords together include a plurality of information words, including encoded patient identification fields, encoded third party insurer identification fields, and encoded fields denominating entitlement and benefit information representative of the relationship between the patient and the third party insurer, said card used by the service provider to verify benefits and entitlement prior to service, and to complete a health care claim for submission to said third party payor after the provision of health care benefits.

14. A health care data card for completing health care claims to be filed electronically as claimed in claim 13 wherein said machine readable data file is encoded in a two dimensional bar code format.

15. A health care data card for completing health care claims to be filed electronically as claimed in claim 13 wherein said machine readable data file is encoded in a PDF417 format.

16. A health care data card for completing health care claims to be filed electronically as claimed in claim 13 wherein said machine readable data file encodes said patient identification fields and said third party insurer identification fields in a standard field format to enable said service provider to electronically file multiple claims from different data cards issued by different insurers with a health care claims clearing house in a single data transmission.

17. A method of filing health care claims electronically when health care services are provided to a patient by a service provider and paid by a third party payor upon the receipt of a medical claim pursuant to a health care insurance policy, said method comprising:

(a) encoding a health care data card with a machine readable data file, said data file including a two dimensional pattern of marks wherein the encoded marks together include a plurality of information words, including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the payor;

(b) imprinting the card with human readable indicia and issuing the card to a patient to be carried by the patient for a period as defined by said insurance policy,

(c) scanning the machine readable data file at a service provider facility and decoding said two dimensional pattern of marks into a plurality of separated patient digital fields and insurer digital fields, each of said fields enabling one or more information words to be decoded therefrom;

(d) entering a plurality of service provider digital fields at said service provider facility, said service provider digital fields representing at least one service provided to said patient,

(e) interleaving said separated patient digital fields and said insurer digital fields from said scanning step and said plurality of service provider digital fields from said entering step and assembling said fields electronically to form a health care claim to be presented to said payor for payment thereof on behalf of the patient;

(f) assembling one or more health care claims for services rendered to one or more patients by said service provider; and

(g) electronically transmitting said health care claim(s) for services rendered to said patients(s) by said service provider to said insurer via a common carrier data communication.

18. An apparatus for filing health care claims electronically when health care services are provided to a patient by a service provider and paid by a third party payor upon the receipt of a medical claim pursuant to a health care policy, said apparatus comprising:

(a) a scanner for scanning a machine readable data file encoded on a health care data card carried by the patient, said data file including a two dimensional pattern of marks wherein the encoded marks together include a plurality of information words, including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the third party payor;

(b) a decoding means for decoding said two dimensional pattern of marks into a plurality of separated patient digital fields and payor digital fields, each of said fields enabling one or more information words to be decoded therefrom;

(c) data entry means for entering a plurality of service provider digital fields entered by said service provider, said service provider digital fields representing service provided to said patient,

(d) a data processing means for receiving said separated patient digital fields and said insurer digital fields from said reader, and said plurality of service provider digital fields entered by said service provider, said data processing means assembling said fields to form a health care claim to be presented to said payor for payment thereof on behalf of the patient;

(e) data memory means for storing one or more health care claims for services rendered to one or more patients by said service provider;

(f) data communication means for transmitting one or more health care claims from said service provider to said payor via a common carrier.

19. A system for assembling, filing and processing health care claims made by patients pursuant to coverage policies issued to the patients by claim payors for service provided to the patients at health care facilities, the network comprising:

a multitude of participating patients, each of the patients having a respective one portable personal data file including a set of patient related data including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the payor and encoded in a machine readable format;

a multitude of health care facilities, for providing health care services to the participating patients, each of the health care facilities having

i) a telecommunications unit, and

ii) a file reader to read the data on the personal data files and to transmit the patient related data to the telecommunications unit at the facility, wherein the telecommunications unit includes a control program having (1) a series of prompts, and (2) a claim assembling program to present the prompts in a human understandable format to solicit from an operator data related to services provided to the patients at the health care facility, and to assemble the patient related data from the personal data files and the service related data from the operator into electronic claim forms;

a plurality of claim payor companies having telecommunications units;

a central clearinghouse connected to the telecommunications units of the health care facilities and connected to the telecommunications units of the claim payor companies, the claims processing unit including

means to receive the electronic claim forms from the health care facilities, to check the electronic claim forms and to transmit said claims to the payor companies for adjudication and payment.

20. A system according to claim 19, wherein each electronic claim form is prepared for an associated service received by one of the patients, and each electronic claim form is prepared at and when the associated service is received by said one of the patients.

21. A computer system for electronically assembling a health insurance claim, each of said claims including patient related data and treatment related data, the system comprising:

a data processing unit;

a memory unit including a claim assembly area;

means connecting the clearinghouse unit and the memory unit together to transmit data therebetween;

input means for receiving data, and including

i) means to receive patient related data including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the payor in an electronic format, and

ii) means to receive input from an operator;

output means for transmitting data from the computer system, and including a screen; and

a control program stored in the data processing unit, and including

i) a series of prompts, and

ii) a claim assembling program to present the prompts on the screen in a predefined order to prompt the operator to input the treatment related data, and to transmit the patient related data and the treatment related data to the claim assembly area to assemble an electronic claim form therein.

22. A computer system according to claim 21, wherein:

the control program further includes a series of data files, identifying possible responses to the prompts; and

the claim assembly program further includes

i) means to display the data files on the screen to help the operator respond to the prompt, and

ii) means to access the data files to change the possible responses identified therein.

23. A computer program for electronically assembling health care claims in a computer system, wherein each of the health care claims includes patient related data and treatment related data, and wherein the program is for use with a computer system including a data processing unit, a memory unit, first input means to receive patient related data in an electronic format, second input means to receive input from an operator, and a screen, the computer program comprising:

a carrier medium; and

a control program stored on the carrier medium, and including

i) a series of prompts, and

ii) a claim assembling program for operating the computer system to present the prompts on the video monitor in a predefined order to prompt the operator to input the treatment related data, and to transmit the patient related data including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the payor and the treatment related data to the memory area of the computer system to assemble an electronic claim form in said memory area.

24. A computer program according to claim 23, wherein:

the control program further includes a series of data files for holding possible responses to the prompts; and

the claim assembling program is adapted to operate the computer system to display the data files on the screen to help the operator respond to the prompts, and to access the data files to change the possible responses held therein.

25. A system for processing insurance claims for services received by patients, the system comprising:

a portable personal data file including a set of data related to a patient including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the payor and encoded in a machine readable format;

a local telecommunications unit including

i) input means for receiving input data from an operator,

ii) output means,

iii) a memory unit,

iv) a control program, and

v) a series of prompts stored in the memory area for soliciting input data from the operator related to services received by the patient; and

a reader for reading the patient related data from the portable personal data file and transmitting said patient related data to the processing unit;

wherein the control program operates (i) to present the prompts on the output means in a human understandable format and in an order determined in accordance with a preset program, to solicit from the operator the treatment related data, and (ii) to assemble the patient related data received from the reader and the treatment related data received from the operator, in the memory area to form an electronic claim form therein.

26. A system according to claim 25, wherein each claim is made pursuant to a coverage policy, and the system further comprises:

a central claims processing unit;

means to transmit the electronic claim form from the local telecommunications unit to the central claims processing unit;

the central processing unit further includes means to adjudicate the electronic claim form in accordance with the coverage policy to determine a response to the claim.

27. A system according to claim 26, wherein the means to transmit the electronic claim form includes:

a common carrier of electronic data;

a modem connected to the local telecommunications unit and the common carriers for receiving the electronic claim form from the local processing unit and converting the electronic claim form into a format suitable for transmission over the common carrier.

28. A method for processing insurance claims for services received by patients, the method comprising:

providing a two-dimensional portable personal data file including a set of data related to a patient including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the payor and encoded in a machine readable format;

providing a local telecommunications unit including a memory section;

using a machine to read the patient related data from the portable personal data file and to transmit said patient related data to the telecommunications unit;

presenting a series of prompts to an operator, in an order determined in accordance with a preset program, to solicit from the operator input data related to services received by the patient;

responding to the prompts by inputting to the telecommunications unit the service related data; and

assembling the patient related data and the treatment related data in the memory section of the telecommunications unit to form an electronic claim form therein.

29. A method according to claim 28, further including the steps of:

providing a central claims clearinghouse unit to forward the electronic claim form to the correct insurance company;

transmitting the electronic claim form from the local telecommunications unit to the central claims processing unit; and

operating the central claim processing unit to adjudicate the electronic claim form, and to determine a response thereto.