Interactive determination of adjudication status of medical claims

Abstract

Claims processing systems for electronically reviewing and adjudicating medical insurance claims. The claims processing systems include a benefits system, an automated adjudication system, a payment system, and a payment tracking system. The benefits system allows patients and health care providers to access patient and benefits information online. Health care providers may electronically receive partially completed claim forms containing patient and benefit information. Health care providers complete the claim forms with proposed health care treatment information and check whether the proposed claim qualifies for automated adjudication. The health care provider may amend unqualified claims in an effort to achieve automated adjudication prior to claim submission. The claims processing system performs automated adjudication on qualified claims. The payment system initiates payment to the health care provider using electronic funds transfer. The payment tracking system allows health care providers to monitor the payment status of a claim after submission.

What is claimed is:  
     
         1 . In a system for processing health insurance claims, the system including an automated adjudication component that automatically adjudicates qualified claims submitted for payment, a method of interactively assisting a health care provider to prepare a health insurance claim that can be automatically adjudicated, comprising the acts of: 
 receiving an electronic claim form from a computer associated with the health care provider, wherein the electronic claim form includes information regarding proposed health care treatment to be provided to a patient;    in response to receiving the electronic claim form, transmitting information to the computer associated with the health care provider to indicate whether a claim associated with the electronic claim form qualifies for automated adjudication so that the health care provider may know, before the proposed health care treatment is provided, whether the claim qualifies for automated adjudication;    if the claim qualifies for automated adjudication, receiving a submitted claim for processing from the computer associated with the health care provider after the proposed health care treatment corresponding with the claim is provided to the patient by the health care provider; and    if the claim does not qualify for automated adjudication, receiving a modified claim from the computer associated with the health care provider that qualifies the claim for automated adjudication, the modified claim submission comprising information regarding new proposed health care treatment.    
     
     
         2 . A method as recited in  claim 1 , further comprising, prior to the health care provider providing the proposed health care treatment, the act of determining whether the claim associated with the electronic claim form qualifies for automated adjudication by considering at least one of the type of proposed health care treatment, compensation sought for the proposed health care treatment, a typical cost associated with the proposed health care treatment, the identity of the health care provider, a medical history of the patient, and patient benefit information.  
     
     
         3 . A method as recited in  claim 1 , further comprising, prior to the health care provider providing the proposed health care treatment, the act of determining whether the claim associated with the electronic claim form qualifies for automated adjudication by considering at least one of current medical practices and preferred insurance practices.  
     
     
         4 . A method as recited in  claim 1 , wherein the electronic claim form comprises at least one of a diagnosis claim form and a treatment claim form.  
     
     
         5 . A method as recited in  claim 1 , wherein the act of transmitting information comprises providing the health care provider a notice that the proposed health care treatment requires preauthorization.  
     
     
         6 . A method as recited in  claim 1 , wherein the act of transmitting information comprises providing the health care provider a notice of an amount of compensation that will be paid to the health care provider for providing the proposed health care treatment to the patient.  
     
     
         7 . A method as recited in  claim 1 , wherein the act of transmitting information comprises determining whether the claim exhibits indicia of fraud, wherein claims exhibiting indicia of fraud are not qualified for automated adjudication.  
     
     
         8 . A method as recited in  claim 8 , wherein determining whether the claim exhibits indicia of fraud comprises the act of determining whether the proposed health care treatment is consistent with an unbundling reporting practice.  
     
     
         9 . A method as recited in  claim 1 , further comprising, if the claim qualifies for automated adjudication, the act of initiating payment of the claim by transmitting information that ultimately results in an electronic transfer of funds to the health care provider.  
     
     
         10 . A method as recited in  claim 10 , further comprising the act of enabling the health care provider to track the status of the submitted claim using a payment tracking component which is in communication with the adjudication component, wherein the payment tracking component allows the health care provider to review, online, the payment status of all submitted claims qualified for automated adjudication.  
     
     
         11 . A method as recited in  claim 1 , wherein the electronic claim form received from the health care provider further comprises patient and benefit information that is retrieved by the health care provider from a health care benefit component of the system and that is necessary to submit a claim for health care treatment.  
     
     
         12 . A method as recited in  claim 11 , wherein the patient and benefit information comprises at least one of the patient's personal, medical, and benefits information.  
     
     
         13 . A method as recited in  claim 11 , wherein the patient and the patient's employer have access to the patient and benefit information.  
     
     
         14 . A method as recited in  claim 13 , wherein the patient and patient's employer can modify the patient and benefit information.  
     
     
         15 . A method as recited in  claim 13 , wherein the patient and benefit information which is retrieved by the health care provider from the health care benefit component is updated by the health care benefit component in response to updating input received from at least one of the patient and the patient's employer.  
     
     
         16 . In a system comprising an automated adjudication component that determines whether claims are qualified for automated adjudication and payment and a health care benefit component that stores patient and benefit information and allows access to the information by a patient, the patient's employer, and a health care provider, a method for submitting and adjudicating claims comprising the acts of: 
 receiving an electronic claim form from the health care provider, wherein the electronic claim form comprises: 
 patient and benefit information which is provided to the health care provider by the health care benefit component in a partially completed electronic claim form which is necessary to submit a claim for health care treatment;  
 information provided by the health care provider regarding proposed health care treatment to be provided to the patient;  
   determining whether the claim corresponding with the electronic claim form qualifies for automated adjudication based on whether the proposed health care treatment conforms with at least one of current medical practices and preferred insurance practices, so that before the proposed health care treatment is provided and the claim is submitted for processing, the health care provider may know whether the claim is qualified for automated adjudication and automatic payment;    if the claim qualifies for automated adjudication, providing notice to the health care provider that the claim qualifies for automated adjudication; and    if the claim does not qualify for automated adjudication, providing notice to the health care provider that the claim qualifies for automated adjudication.    
     
     
         17 . A method as recited in  claim 16 , wherein determining whether the claim corresponding with the electronic claim form qualifies for automated adjudication further comprises considering at least one of the type of proposed health care treatment, compensation sought for the proposed health care treatment, a typical cost associated with the proposed health care treatment, the identity of the health care provider, a medical history of the patient, and patient benefit information.  
     
     
         18 . A method as recited in  claim 17 , wherein determining whether the claim corresponding with the electronic claim form qualifies for automated adjudication further comprises determining whether the claim exhibits indicia of fraud.  
     
     
         19 . A method as recited in  claim 16 , wherein the patient and benefit information which is provided to the health care provider by the health care benefit component comprises updated patient and benefit information which has been updated by the health care benefit component in response to input received by at least one of the patient and the patient's employer.  
     
     
         20 . In a system comprising an automated adjudication component that determines whether claims are qualified for automated adjudication and payment and a health care benefit component that stores patient and benefit information and allows access to the information by a patient, the patient's employer, and a health care provider, a method for submitting and adjudicating claims comprising the acts of: 
 receiving an electronic claim form from the health care provider, wherein the electronic claim form comprises: 
 patient and benefit information which is provided to the health care provider by the health care benefit component in a partially completed electronic claim form which is necessary to submit a claim for health care treatment;  
 information provided by the health care provider regarding proposed health care treatment to be provided to the patient;  
   determining whether the claim corresponding with the electronic claim form qualifies for automated adjudication based on whether the proposed health care treatment conforms with at least one of current medical practices and preferred insurance practices, so that before the proposed health care treatment is provided and the claim is submitted for processing, the health care provider may know whether the claim is qualified for automated adjudication and automatic payment;    if the claim qualifies for automated adjudication, providing notice to the health care provider that the claim qualifies for automated adjudication; and    if the claim is not qualified for automated adjudication, performing the acts of: 
 providing notice to the health care provider that the claim does not qualify for automated adjudication.  
 receiving from the health care provider the electronic claim form with modified information regarding new proposed health care treatment that qualifies the claim for automated adjudication;  
 providing notice to the health care provider that the claim with new proposed health care treatment qualifies for automated adjudication; and  
 initiating payment of the claim by transmitting information to an automatic payment component associated with the system that ultimately results in an electronic transfer of funds to the health care provider.  
   
     
     
         21 . A method as recited in  claim 20 , wherein determining whether the claim corresponding with the claim form qualifies for automated adjudication further comprises considering at least one of the type of proposed health care treatment, compensation sought for the proposed health care treatment, a typical cost associated with the proposed health care treatment, the identity of the health care provider, a medical history of the patient, and patient benefit information.  
     
     
         22 . A method as recited in  claim 20 , further comprising the act of enabling the health care provider to track the status of the submitted claim using a payment tracking component of the system, wherein the payment tracking component allows the health care provider to review, online, the payment status of all submitted claims qualified for automated adjudication.