Pre-Grant Publication Number: 20090070135
System and method for improving claims processing in the healthcare industry
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#473US20060020495A1: Healthcare Claims Processing Mechanism for a Transaction System
Applies to Claims 1,11,19,2,3
Submitted by: Diane WillisLast updated: almost 4 years ago
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Summary / Description
Summary / DescriptionHealthcare claims management and payment transaction system generates and transmits message representing payment authorization, to payment mechanism, based on transmitted registration and claim information
 
Basic Information
Type of Prior ArtIssued Patents - US
 
CountryUnited States of America
 
Patent/Application #US20060020495A1
 
Kind CodeUnited States (US) - United STATES Patent - A
 
Patentee NameBaker, Michael Stephen; Jenkins, Stephen Reed; Bornacorso, John I; Platz, Stephen James;
 
Relevant Pages, Columns, or Lines[0011], [0012], [0013]
 
URL
 
Filing DateJuly 20, 2004
 
Additional Information
 
Notes / To Do
Notes
 
Excerpt
Excerpt
At the time healthcare services are rendered to a participant, the participant may present system identification information 263 to the healthcare provider(s) 221, sufficient to identify the participant in the system of the present invention. The healthcare provider 221 transmits this information, along with claim information 261 relating to the services provided to the participant, to the claim processing mechanism 231 of the present invention by means of the claim submission mechanism 232; alternatively, a participating employee may submit the claim directly to the claim processing mechanism 231 by means of the claim submission mechanism 232. The claim processing mechanism 231 may then perform some or all of the following steps: confirm that the participant is enrolled (eligibility confirmation 235); attach or incorporate certain information as regards the participant, the applicable employer, the healthcare provider 221, the funded account 271 and the provider's account 272 (which information was gathered through the registration process by any or each of them and is stored in the database 240) to the claim information submitted (information association 236); compare the claim information 261 to the applicable template(s) and rule set(s) 250 (template validation 237); and confirm that the applicable funded account 271 has sufficient funds available to the participant to satisfy the claim 261 in whole or in part (funds confirmation 238). Upon completion of any or all of said steps, the claim processing mechanism 231 may transmit a message 306 to the financial institution 225 holding the funded account 271 to transfer the claim amount (or lesser amount) from the funded account 271 to the applicable user account 272. The financial institution 225, after receipt of claim payment authorization 306, issues fund transfer instructions 307 causing funds to be transferred from the funded account 271 to the applicable user account 272; upon successful transfer of the funds, the financial institution 225 may generate a transfer confirmation message 308 to the claims processing mechanism 231. The claim processing mechanism 231 may further transmit the claim information 261, applicable registration information 262 and payment authorization 306, reformatted and filtered as desirable, to the insurance provider 227 by means of the insurance submission mechanism 236. 1. Claim processing Referring to FIGS. 1, 2 and 3, when a healthcare provider 221 provides healthcare services to a participant (at S201), the participant provides system identification information 263 to the healthcare provider 221, who then inputs and transmits (at S202) the claim information 261 for said services and the participant's system identification information 263 to the claim processing mechanism 231, by means of the claim submission mechanism 232. Multiple claims 261 for one or more participants may be entered by the healthcare provider 221 sequentially in a batch. Upon receipt of the message comprising the claim information 261, the claim processing mechanism 231 then performs some or all of the following steps, in any logical order: .....
 
Relevance
Claims
1
A method for managing clinical documents for claims processing, said method comprising:receiving a command to submit an invoice to a payer;acquiring a first set of files from an electronic medical records database according to a first set of rules, wherein said first set of rules provide for acquiring a first set of files required for submission to a payer;displaying an identifier for said first set of files to a user for approval, wherein if said user approves of the acquisition of said first set of files, electronically transmitting said first set of files to said payer.
Relevance
Disclosed in the prior art, including information provided in the Excerpt, is a process for processing healthcare invoices.
Disclosed in the prior art, including information provided in the Excerpt, is a process for processing healthcare invoices.
Claim Chart
Some
2
The method of Claim 1, further comprising receiving a request for additional information from said payer.
Relevance
[0017] references: (b) Validation of Claims to Template/Rule Sets The claim information 261 is compared to the applicable template(s) and/or rule set(s) 250 (at S204, template validation 237). If the claim information does not comply with the applicable template(s) and/or rule set(s) 250, a message 281 to that effect may be generated and transmitted (at S205) to some or all of the users 228. The healthcare provider 221 may then correct and retransmit the claim information 261 (at S202), or the corrections thereto, to the claim processing mechanism 231, by means of the claim submission mechanism 234, for comparison to the applicable template(s) and/or rule set(s) 250. The corrections to the claim information 261 may be attached to, incorporated in, or otherwise associated with the claim information 261, or the corrections may modify the claim information 261 as originally submitted by the healthcare provider 221.
[0017] references: (b) Validation of Claims to Template/Rule Sets The claim information 261 is compared to the applicable template(s) and/or rule set(s) 250 (at S204, template validation 237). If the claim information does not comply with the applicable template(s) and/or rule set(s) 250, a message 281 to that effect may be generated and transmitted (at S205) to some or all of the users 228. The healthcare provider 221 may then correct and retransmit the claim information 261 (at S202), or the corrections thereto, to the claim processing mechanism 231, by means of the claim submission mechanism 234, for comparison to the applicable template(s) and/or rule set(s) 250. The corrections to the claim information 261 may be attached to, incorporated in, or otherwise associated with the claim information 261, or the corrections may modify the claim information 261 as originally submitted by the healthcare provider 221.
Claim Chart
Some
3
The method of Claim 2, further comprising acquiring a second set of files from said electronic medical records database according to a second set of rules, wherein said second set of rules provide for acquiring a second set of files that supplement said first set of files for submission to said payer.
Relevance
See the Excerpt and information submitted for Claims 1 and 2.
See the Excerpt and information submitted for Claims 1 and 2.
Claim Chart
Some
11
A computer readable medium including a set of instructions for execution by a computer, said set of instructions comprising:a receiving routine for receiving a command to submit an invoice to a payer for services rendered to a patient;an acquisition routine for acquiring a first set of files from an electronic medical records database according to a first set of rules, wherein said first set of rules provide for acquiring a first set of files required for submission to a payer;a displaying routine for displaying an identifier for said first set of files to a user for approval, wherein if said user approves of the acquisition of said first set of files, electronically transmitting said first set of files to said payer.
Relevance
See the Excerpt.
See the Excerpt.
Claim Chart
Some
19
A system for managing clinical documents for claims processing, said system comprising:a client unit having computer software for receiving a command to submit an invoice to a payer for services rendered to a patient, wherein said invoice includes a primary tag;wherein said client unit acquires a first set of files from an electronic medical records database according to a first set of rules, wherein said first set of rules provide for acquiring a first set of files required for submission to a payer, wherein said first set of files is associated with said primary tag;a display unit for displaying an identifier for said first set of files to a user for approval, wherein if said user approves of the acquisition of said first set of files, electronically transmitting said first set of files to said payer.
Relevance
See the Excerpt.
See the Excerpt.
Claim Chart
Some
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