公开(公告)号：US07797172B2

公开(公告)日：2010-09-14

申请号：US10253223

申请日：2002-09-24

申请人： David Fitzgerald ,  Brian Lucas ,  Greg Long ,  David Hiebert Klassen, Sr. ,  John Hunter

发明人： David Fitzgerald ,  Brian Lucas ,  Greg Long ,  David Hiebert Klassen, Sr. ,  John Hunter

IPC分类号： G06Q40/00

CPC分类号： G06F19/328 ,  G06F19/00 ,  G06Q20/102 ,  G06Q40/02 ,  G06Q40/08 ,  G06Q50/22

摘要： A patient claim data processing system responds to and initiates clinical events and attains early accurate claim data during a patient healthcare encounter cycle to support prompt claim data validation and editing both for individual claim elements and for a completed claim to improve claim accuracy prior to claim submission to a payer. The system submits accurate claims to payers and receives remittance advice from payers and applies rules to the advice. A system processes financial data related to provision of healthcare to a patient in response to clinical events. The system includes an interface processor for receiving a message identifying an event and a related change in healthcare data concerning a patient and also includes a source of rules for determining characteristics associated with reimbursement for provision of an individual service to a patient. A rules processor initiates application of a rule derived from the rules source to process financial data concerning provision of the individual service to the patient in response to receiving the message identifying the event. A result processor initiates an action in response to a result derived by the application of the rule to process the financial data. The rules processor also validates the financial data complies with the rule.

摘要翻译： 患者索赔数据处理系统响应并启动临床事件，并在患者医疗保健相关周期期间获得早期准确的索赔数据，以支持针对个人索赔要素的即时索赔数据验证和编辑，以及完成的索赔，以在索赔提交之前提高索赔准确性 付款人 系统向付款人提交准确的索赔，并从付款人那里收到汇款通知，并对建议采用规则。 系统响应于临床事件处理与向患者提供医疗保健有关的财务数据。 该系统包括接口处理器，用于接收标识事件的消息和关于患者的医疗保健数据的相关变化，并且还包括用于确定与向患者提供个体服务的报销相关联的特征的规则来源。 响应于接收到标识事件的消息，规则处理器启动从规则源导出的规则的应用以处理关于向患者提供单独服务的财务数据。 结果处理器响应于应用规则导出的结果来处理财务数据而发起操作。 规则处理器还验证财务数据符合规则。

公开(公告)号：US07917378B2

公开(公告)日：2011-03-29

申请号：US10247980

申请日：2002-09-20

申请人： David Fitzgerald ,  Brian Lucas ,  Greg Long ,  David Hiebert Klassen, Sr. ,  John Hunter ,  Jon Zimmerman

发明人： David Fitzgerald ,  Brian Lucas ,  Greg Long ,  David Hiebert Klassen, Sr. ,  John Hunter ,  Jon Zimmerman

IPC分类号： G06Q40/00 ,  G06Q10/00 ,  G06Q50/00

CPC分类号： G06Q50/22 ,  G06F19/00 ,  G06F19/328 ,  G06Q10/10 ,  G06Q40/08 ,  G16H10/60 ,  G16H15/00 ,  G16H50/20

摘要： A claim pre-processing system employs trial adjudication to improve claim accuracy prior to claim submission to a healthcare payer institution or other entity. A system processes claim data related to provision of healthcare to a patient The system includes a claim data collator for collating data related to a claim for a particular patient for submission to a payer and a source of rules for use in processing collated claim data. A pre-processor submits the collated claim data for processing using the rules to validate the collated claim data is in condition for processing to initiate generation of payment. A claim processor submits the collated claim data to a payer, in response to successful validation by the pre-processor. A rules processor processes acquired claim data to identify a condition triggering application of a different set of rules for determining validity of an individual claim element. The pre-processor re-submits amended collated claim data for processing using the rules to validate the collated claim data is in condition for processing to initiate generation of payment, the amended collated claim data being received in response to unsuccessful validation using the rules.

摘要翻译： 索赔预处理系统在提交给医疗支付机构或其他实体之前，采用审判裁决来提高索赔准确性。 系统处理与向患者提供医疗保健相关的索赔数据。该系统包括权利要求数据整理器，用于对与特定患者的权利要求相关的数据进行整理，以提交给付款人以及用于处理整理的索赔数据的规则来源。 预处理器使用规则提交整理的索赔数据进行处理，以验证整理的索赔数据处于开始生成付款的条件。 响应于预处理器的成功验证，索赔处理器将分类的索赔数据提交给付款人。 规则处理器处理获取的权利要求数据以识别触发应用不同的规则集合以确定个人权利要求元素的有效性的条件。 预处理器重新提交经修订的对照索赔数据，以便使用规则进行处理，以验证整理的索赔数据处于启动付款生成条件的条件下，修改后的整理索赔数据是响应于使用规则的不成功验证而收到的。