Systems and Methods for Processing Claims in Real-Time

Abstract

Claim processing system providing an interface to permit pharmacy and medical management systems to use the Internet to transmit third-party insurance claims on a claim-by-claim basis in real-time or near-real-time to one or more claim servers that receive insurance claim requests over the Internet in an encrypted form. The one or more claim servers decrypt the claim requests and forward them to a health network application which facilitates the submission of the claims to insurance payers and the response of the insurance payers to the requests. Payer responses are received by the claim servers, encrypted and forwarded to the pharmacy and medical management systems in real-time or near real-time.

1 . A claim handling system for facilitating the real-time processing of claims, said claim handling system comprising:
 a secure claim transmission application (SCTA) being configured for executing the steps of:
 receiving a plurality of claims from a practice management system, wherein each one of said plurality of claims identifies a payer to which the claim is directed; 
 generating a different encryption key for transmitting each one of said plurality of claims to a claim server; 
 receiving an encrypted claim response from said claim server for each one of said plurality of claims, wherein said encrypted claim response corresponds to a response generated by said payer to a corresponding claim transmitted to said payer by said claim server; 
 decrypting each one of said encrypted claim responses corresponding to each one of said plurality of claims; and 
 making available each of said decrypted claim responses to said practice management system, wherein each decrypted claim response is received by said SCTA in real-time or near real-time in response to the transmission to said claim server of said claim corresponding to said decrypted claim response. 
   
     
     
         2 . The claim handling system of  claim 1 , wherein said SCTA is further configured for executing the step of configuring each one of said plurality of claims for transmission to a claim server. 
     
     
         3 . The claim handling system of  claim 2 , wherein said SCTA is further configured for executing the step of altering said format of each of one of said plurality of claims prior to their respective transmission to said claim server. 
     
     
         4 . The claim handling system of  claim 1 , wherein said SCTA is further configured for executing the step of directing the transmission of each one of said plurality of claims to said claim server. 
     
     
         5 . The claim handling system of  claim 1 , wherein said SCTA is further configured for executing the step of setting up a secure session with said claim server through which at least one of said plurality of claims is transmitted to said claim server. 
     
     
         6 . The claim handling system of  claim 5 , wherein said SCTA is further configured to exchange secure tokens with said claim server to set up said secure connection with said claim server. 
     
     
         7 . The claim handling system of  claim 1 , wherein said SCTA is further configured for executing the step of identifying a header within at least one of said plurality of claims, wherein said header identifies said at least one of said plurality of claims as directed to said payer. 
     
     
         8 . The claim handling system of  claim 1 , wherein said step of generating a different encryption key for transmitting each one of said plurality of claims to a claim server further comprises the steps of:
 requesting a secure connection with said claim server;   receiving a secure connection response from said claim server; and   
       examining said secure connection response to verify the authenticity of said claim server. 
     
     
         9 . The claim handling system of  claim 1 , wherein said step of making available each of said decrypted claim responses to said practice management system comprises the step of allowing the practice management system to read each of said claim responses from a serial interface controlled by said SCTA. 
     
     
         10 . The claim handling system of  claim 1 , wherein said step of making available each of said decrypted claim responses to said practice management system comprises the step of allowing the practice management system to read each of said claim responses from a directory controlled by said SCTA. 
     
     
         11 . A method for facilitating the real-time processing of claims, comprising:
 receiving a plurality of claims from a practice management system, wherein each one of said plurality of claims identifies a payer to which the claim is directed;
 generating a different encryption key for transmitting each one of said plurality of claims to a claim server; 
 receiving an encrypted claim response from said claim server for each one of said plurality of claims, wherein said encrypted claim response corresponds to a response generated by said payer to a corresponding claim transmitted to said payer by said claim server; 
 decrypting each one of said encrypted claim responses corresponding to each one of said plurality of claims; and 
 making available each of said decrypted claim responses to said practice management system, wherein each decrypted claim response is received by said practice management system in real-time or near real-time in response to the transmission to said claim server of said claim corresponding to said decrypted claim response. 
   
     
     
         12 . The method of  claim 11 , further comprising the step of configuring each one of said plurality of claims for transmission to a claim server. 
     
     
         13 . The method of  claim 12 , further comprising the step of altering said format of each of one of said plurality of claims prior to their respective transmission to said claim server. 
     
     
         14 . The method of  claim 11 , further comprising the step of directing the transmission of each one of said plurality of claims to said claim server. 
     
     
         15 . The method of  claim 11 , further comprising the step of setting up a secure session with said claim server through which at least one of said plurality of claims is transmitted to said claim server. 
     
     
         16 . The method of  claim 15 , further comprising the step of exchanging secure tokens with said claim server to set up said secure connection with said claim server. 
     
     
         17 . The method of  claim 11 , further comprising the step of identifying a header within at least one of said plurality of claims, wherein said header identifies said at least one of said plurality of claims as directed to said payer. 
     
     
         18 . The method of  claim 11 , wherein the step of generating a different encryption key for transmitting each one of said plurality of claims to a claim server further comprises the steps of:
 requesting a secure connection with said claim server;   receiving a secure connection response from said claim server; and   examining said secure connection response to verify the authenticity of said claim server.   
     
     
         19 . The method of  claim 11 , wherein the step of making available each of said decrypted claim responses to said practice management system comprises the step of allowing the practice management system to read each of said claim responses from a serial interface to which the claim responses were written. 
     
     
         20 . The claim handling system of  claim 11 , wherein said step of making available each of said decrypted claim responses to said practice management system comprises the step of allowing the practice management system to read each of said claim responses from a directory to which the claim responses were written.