Systems and methods for the intelligent coordination of benefits in healthcare transactions
First Claim
1. A computer-implemented method, comprising:
- receiving a healthcare claim request from a healthcare provider computer, the healthcare claim request including patient information identifying a patient, and product information identifying a product for the patient;
determining, based at least in part from a portion of the patient information in the healthcare transaction claim request, that the patient is associated with at least a first payer and a second payer, wherein the determining includes;
transmitting an eligibility request to an eligibility verification computer, the eligibility request including at least a portion of the patient information in the healthcare transaction claim request, andreceiving, from the eligibility verification computer, an eligibility reply that identifies at least two payers associated with the patient, wherein the eligibility reply includes respective cardholder identifiers for the at least two payers, wherein the cardholder identifiers identify the account holder for each respective payer, wherein the cardholder identifiers are different for each respective payer,wherein the respective cardholder identifiers for the at least two payers are utilized to determine which of the at least two payers is the first payer or the second payer;
generating a primary claim request based upon the identified product and the patient associated with the healthcare claim request, the primary claim associated with the first payer;
communicating the generated primary claim request to a first claims processor computer associated with the first payer for adjudication;
receiving, from the first claims processor computer, a first adjudicated reply for the primary claim, the first adjudicated reply indicating first financial coverage information for the identified product for the patient;
generating a coordination of benefits (COB) claim request based at least in part on the received first adjudicated reply, the COB claim request including at least a portion of the first financial coverage information for the identified product, the COB claim request associated with a second payer;
communicating the generated COB claim request to a second claims processor computer associated with the second payer for adjudication;
receiving, from the second claims processor computer, a second adjudicated reply for the COB claim; and
communicating information associated with the first adjudicated reply and the second adjudicated reply to the healthcare provider computer,wherein the above operations are performed by one or more computers associated with a service provider.
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0 Petitions
Accused Products
Abstract
Systems and methods are provided for the coordination of benefits. The systems and methods may include receiving a healthcare claim request from a healthcare provider computer; determining, based at least in part from patient information in the healthcare transaction claim request, that the patient is associated with at least a first payer and a second payer; generating a primary claim request based upon the identified product and the patient associated with the healthcare claim request, the primary claim associated with the first payer; and generating a coordination of benefits (COB) claim request based at least in part on the received first adjudicated reply associated with the primary claim request, the COB claim request, the COB claim request associated with a second payer.
234 Citations
13 Claims
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1. A computer-implemented method, comprising:
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receiving a healthcare claim request from a healthcare provider computer, the healthcare claim request including patient information identifying a patient, and product information identifying a product for the patient; determining, based at least in part from a portion of the patient information in the healthcare transaction claim request, that the patient is associated with at least a first payer and a second payer, wherein the determining includes; transmitting an eligibility request to an eligibility verification computer, the eligibility request including at least a portion of the patient information in the healthcare transaction claim request, and receiving, from the eligibility verification computer, an eligibility reply that identifies at least two payers associated with the patient, wherein the eligibility reply includes respective cardholder identifiers for the at least two payers, wherein the cardholder identifiers identify the account holder for each respective payer, wherein the cardholder identifiers are different for each respective payer, wherein the respective cardholder identifiers for the at least two payers are utilized to determine which of the at least two payers is the first payer or the second payer; generating a primary claim request based upon the identified product and the patient associated with the healthcare claim request, the primary claim associated with the first payer; communicating the generated primary claim request to a first claims processor computer associated with the first payer for adjudication; receiving, from the first claims processor computer, a first adjudicated reply for the primary claim, the first adjudicated reply indicating first financial coverage information for the identified product for the patient; generating a coordination of benefits (COB) claim request based at least in part on the received first adjudicated reply, the COB claim request including at least a portion of the first financial coverage information for the identified product, the COB claim request associated with a second payer; communicating the generated COB claim request to a second claims processor computer associated with the second payer for adjudication; receiving, from the second claims processor computer, a second adjudicated reply for the COB claim; and communicating information associated with the first adjudicated reply and the second adjudicated reply to the healthcare provider computer, wherein the above operations are performed by one or more computers associated with a service provider. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9)
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10. A system, comprising:
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at least one memory operable to store computer-executable instructions; and at least one processor configured to access the at least one memory and execute the computer-executable instructions to; receive a healthcare claim request from a healthcare provider computer, the healthcare claim request including patient information identifying a patient, and product information identifying a product for the patient; determine, based at least in part from a portion of the patient information in the healthcare transaction claim request, that the patient is associated with at least a first payer and a second payer by, transmitting an eligibility request to an eligibility verification computer, the eligibility request including at least a portion of the patient information in the healthcare transaction claim request, and receiving, from the eligibility verification computer, an eligibility reply that identifies at least two payers associated with the patient, wherein the eligibility reply includes respective cardholder identifiers for the at least two payers, wherein the cardholder identifiers identify the account holder for each respective payer, wherein the cardholder identifiers are different for each respective payer, and wherein the respective cardholder identifiers for the at least two payers are utilized to determine which of the at least two payers is the first payer or the second payer; generate a primary claim request based upon the identified product and the patient associated with the healthcare claim request, the primary claim associated with the first payer; communicate the generated primary claim request to a first claims processor computer associated with the first payer for adjudication; receive, from the first claims processor computer, a first adjudicated reply for the primary claim, the first adjudicated reply indicating first financial coverage information for the identified product for the patient; generate a coordination of benefits (COB) claim request based at least in part on the received first adjudicated reply, the COB claim request including at least a portion of the first financial coverage information for the identified product, the COB claim request associated with a second payer; communicate the generated COB claim request to a second claims processor computer associated with the second payer for adjudication; receive, from the second claims processor computer, a second adjudicated reply for the COB claim; and communicate information associated with the first adjudicated reply and the second adjudicated reply to the healthcare provider computer. - View Dependent Claims (11, 12, 13)
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Specification