Medical Services Claim Management System and Method

Abstract

Methods for managing requests by a medical services provider for payment from a payer are described. In one embodiment, claims are aggregated into a single file and submitted for payment electronically. If a file level rejection occurs, rejected claims are removed and the single file reformed and resubmitted. This is repeated as necessary until the file is accepted. In another embodiment, claims are assigned first unique identifiers and line items in claims are assigned second unique identifiers. The unique identifiers are used to track every transaction. In another embodiment, an explanation of benefits relating to a claim is received and processed. Copayments are reallocated to line items according to the explanation of benefits. Writeoffs and transfers to next payers are performed automatically according to adjudication codes in the explanation of benefits.

1 . A computerized method of managing requests by a health care service provider for payment, the method comprising:
 electronically submitting, by a computer system operated on behalf of the provider, multiple claims in a single file to a computer system operated on behalf of a payer;   responding electronically to any file level rejection by storing a record of the rejection and re-creating the multiple claim file without the rejected claims in the computer system operated on behalf of the provider; and   automatically repeating the acts of submitting and responding, as necessary, until the single file is accepted.   
     
     
         2 . The computerized method of  claim 1 , further comprising:
 associating, by the computer system operated on behalf of the provider, a first unique identifier with each claim submitted for payment;   placing, by the computer system operated on behalf of the provider, the first unique identifier in a field required by standards to be preserved in the course of processing; and   for each claim, in connection with any transaction involving the claim, storing the transaction in association with the first unique identifier for the claim.   
     
     
         3 . The computerized method of  claim 2 , further comprising:
 associating, by the computer system operated on behalf of the provider, a second unique identifier with each line item of a claim to be submitted for payment;   placing, by the computer system operated on behalf of the provider, the second unique identifier in a field required by standards to be preserved in the course of processing; and   for each line item, in connection with any transaction involving the line item, storing the transaction in association with the second unique identifier for the line item.   
     
     
         4 . The computerized method of  claim 2 , further comprising:
 receiving, over a network at the computer system operated on behalf of the provider, an explanation of benefits for at least one of the claims, wherein each explanation of benefits contains the first unique identifier associated with the corresponding claim; and   storing the explanation of benefits in association with the first unique identifier for the claim.   
     
     
         5 . The computerized method of  claim 3 , further comprising:
 receiving, over a network at the computer system operated on behalf of the provider, an explanation of benefits for at least one of the claims, wherein each explanation of benefits contains:
 the first unique identifier associated with the corresponding claim; and 
 the second unique identifiers associated with the line items in the claim; and 
   storing the explanation of benefits in association with the first unique identifier for the corresponding claim and the second unique identifiers for the line items of the corresponding claim.   
     
     
         6 . The computerized method of  claim 5 , wherein the explanation of benefits further contains a co-payment allocation for each line item to which the payer applied a co-payment, the method further comprising:
 reversing any co-payment allocation in the health care service provider system for any line item referenced in the explanation of benefits; and   re-allocating the co-payment in the health care service provider system to the line item to which the co-payment was allocated in the explanation of benefits.   
     
     
         7 . The computerized method of  claim 5 , wherein the explanation of benefits further contains a co-payment allocation for each line item to which the payer applied a co-payment, the method further comprising:
 comparing the line item to which a co-payment is allocated in the explanation of benefits and the line item to which the health care service provider system allocated the co-payment; and   if the line item allocations are not the same:
 reversing the co-payment allocation in the health care service provider system; and 
 re-allocating the co-payment in the health care service provider system to the line item to which the co-payment was allocated in the explanation of benefits. 
   
     
     
         8 . The computerized method of  claim 5 , wherein the explanation of benefits further contains:
 a set of adjudication codes for each line item, wherein each adjudication code in the line item relates to a portion of the associated charge;   the method further comprising:
 for each line item in the explanation of benefits, looking up the adjudication codes in a table of associated actions; 
 if any actions associated with the line item are transfer actions and no actions associated with the line item are suspend actions, transferring any balance remaining in association with the line item to a next payer; 
 if any actions associated with the line item are write-off actions, writing off the portions of associated charge to which the actions relate; and 
 if the line item received any unfavorable adjudication codes, creating an entry for the line item in a denial management queue. 
   
     
     
         9 - 30 . (canceled) 
     
     
         31 . A computerized method of managing requests by a health care service provider for payment, the method comprising:
 electronically submitting, by a computer system operated on behalf of the provider, multiple claims to a payer in a single file, wherein for each claim a first unique identifier associated with the claim and a second unique identifier associated with each line item of the claim are placed in fields required by standards to be preserved during processing;   responding electronically, by the computer system operated on behalf of the provider, to any file level rejection by storing a record of the rejection and re-creating the multiple claim file without the rejected claims;   automatically repeating the acts of submitting and responding, as necessary, until the single file is accepted;   receiving, over a network at the computer system operated on behalf of the provider, an explanation of benefits for at least one of the claims, wherein the explanation of benefits contains:
 the first unique identifier associated with the corresponding claim; 
 the second unique identifiers associated with the line items in the claim; 
 a check number; and 
 a set of adjudication codes for each line item, wherein each adjudication code of the line item relates to a portion of the associated charge; 
   for each line item referenced in the explanation of benefits, looking up the adjudication codes in a table of associated actions;   if any actions associated with the line item are transfer actions and no actions associated with the line item are suspend actions, transferring any balance remaining in association with the line item to a next payer;   if any actions associated with the line item are write-off actions, writing off the portions of the line item to which the actions relate;   if the line item received any unfavorable adjudication codes, creating an entry for the line item in a denial management queue;   identifying a deposit to a health care service provider's bank account, wherein the deposit has the same check number as the explanation of benefits; and   associating the deposit with the claim referenced in the explanation of benefits.   
     
     
         32 . A computerized method of managing requests by a health care service provider for payment, the method comprising:
 electronically submitting multiple claims of the health care service provider in a single electronic file to a computer system operated on behalf of a payer, wherein for each claim a first unique identifier associated with the claim is placed in a field required by standards to be preserved during processing;   receiving, over a network at a computer system operated on behalf of the provider, from the computer system operated on behalf of the payer, explanation of benefits records responsive to the electronically submitted claims, wherein each explanation of benefits record responsive to a given claim contains the first unique identifier corresponding to the given claim;   storing each explanation of benefits record in association with its corresponding first unique identifier;   receiving a settlement check associated with a plurality of the submitted claims of the health care service provider, wherein the computer system operated on behalf of the provider contains a database of claim data and payment data;   for each associated claim:
 associating in the database a portion of the settlement check with the claim according to a distribution strategy; 
 recording in the database a partial payment of the claim in the amount of the associated portion of the settlement check; and 
 applying a settlement adjustment in the database to remaining unpaid balance for the charges associated with the claim. 
   
     
     
         33 . The computerized method of  claim 32 , wherein the distribution strategy comprises:
 calculating a total of all outstanding charges associated with the plurality of claims;   calculating a ratio of a value of the settlement check to the total of all outstanding charges; and   for each of the plurality of claims, associating in the database a portion of the settlement check equal to the outstanding charge associated with the claim reduced by the ratio of the value of the settlement check to the total of all outstanding charges.