Lossless account compression for health care patient benefits eligibility research system and methods

Abstract

A system and method for determining eligibility for reimbursement for medical claims for patients may be implemented with computer software which compares a service provider's patient information against a benefit provider's database of covered persons to determine if the patient is eligible for benefits. The service provider records may be compressed by grouping all of the medical claims relating to a particular patient into one cluster represented by a composite medical claim, which may be used to query the benefit provider databases to determine if the patient is recognized. If the patient is recognized, every record within the cluster may be checked against the benefit provider's database to determine whether one or more patient medical claims are eligible for reimbursement.

1 - 6 . (canceled) 
     
     
         7 . A method for identifying medical claims eligible for reimbursement, comprising:
 sorting medical claims of a service provider into clusters of medical claims and non-clustered medical claims, wherein each of said clusters comprises a group of constituent medical claims all relating to the same patient;   creating a composite medical claim for each of said clusters, wherein each said composite medical claim comprises data representative of all said constituent medical claims within the respective cluster;   executing a query against the benefit provider's database for each said composite medical claim and each said non-clustered medical claim;   receiving an indication as to whether the benefit provider's database contains a record that is responsive to each said query;   for each said indication that is affirmative with respect to one of said non-clustered medical claims for which the benefit provider's database comprises one or more matching records, placing said one of said non-clustered medical claims and said one or more matching records in a file;   for each said indication that is affirmative with respect to one of said composite medical claims, executing an additional query against the benefit provider's database for each said constituent medical claim within the respective cluster associated with said one of said composite medical claims; and   for each said additional query associated with one of said constituent medical claims for which the benefit provider's database comprises one or more additional matching records, placing said one of said constituent medical claims and said one or more additional matching records in said file.   
     
     
         8 . The method of  claim 7  further comprising:
 submitting said non-clustered medical claims and said constituent medical claims for which the benefit provider's database comprises one or more matching records to the benefit provider for reimbursement. 
 
     
     
         9 . The method of  claim 7  further comprising:
 generating a report indicative of a difference in information between one of said medical claims of the service provider and one of said matching records of the benefit provider. 
 
     
     
         10 . The method of  claim 9  wherein said report further comprises an eligibility date for said one of said medical claims. 
     
     
         11 . The method of  claim 10  wherein said eligibility date is retroactive. 
     
     
         12 . The method of  claim 9  wherein said report further comprises a deadline by which said one of said medical claims must be submitted for reimbursement. 
     
     
         13 . The method of  claim 9  wherein said report further comprises an amount of an outstanding balance eligible for reimbursement with respect to a medical claim for which a partial payment has been made. 
     
     
         14 . The method of  claim 9  wherein said report further comprises an indication of an incorrect service code.