METHOD AND SYSTEM FOR ELECTRONICALLY MANAGING AND REIMBURSING MEDICAL CARE

摘要

A system for guiding medical service providers in making referrals and in providing services that are automatically authorized for specified payments. Upon an initial encounter with a patient, the system guides a user through identifying insurance plan member information, verifying patient number and eligibility, and identifying related past encounter. The system then assists the user in creating a referral that authorizes a performing provider to provide certain medical services which are guaranteed to be reimbursed at a determinable level. The system guides the user in specifying a referring and performing provider, a type of facility, a referral basis and treatment type suggestions, and an urgency level. For each specification, the system indicates choices for which the system can automatically authorize a referral that results. The system also assists review users in manually authorizing referrals that the system cannot automatically authorize. When a person seeks care from a preforming provider for which an authorized referral exists, the system retrieves relevant patient medical history and assists a user in specifying authorized diagnosis and service codes, corresponding to the medical diagnoses made and the medical services provided, such that the provider is guaranteed to receive a determinable payment. If diagnosis or service codes are specified for which the system cannot automatically authorize payment, the system assists review users in manually adjucating and authorizing the payment to be received. When services are authorized for payment, the system automatically makes payment.