| 摘要 |
Systems, methods, apparatus, and computer program products are provided for processing claims. In various embodiments, claims can be processed in accordance with a data-driven approach that limits changes to existing claims processing rules by using exclusion tables, inclusion tables, and/or decision tables to change or execute rules in a more efficient manner. |
| 主权项 |
1. A method for processing a claim, the method comprising:
processing, via one or more processors, a current claim line of a claim in accordance (a) with a first claims processing rule and (b) a first support claim line of the claim, wherein the first claims processing rule comprises (a) a rule name and (b) an indication to reference a table in addition to applying the first claims processing rule; determining, via the one or more processors, whether an entry exists in the table for the first claims processing rule based at least in part on the rule name for the first claims processing rule, wherein the entry for the first claims processing rule in the table comprises an indication whether to (a) create a case for the current claim line or (b) consider the current claim line further for creating a case; after determining that an entry exists in the table for the first claims processing rule, determining, via the one or more processors, whether the current claim line and the first support claim line satisfy the requirements of the entry for the first claims processing rule; and after determining that the current claim line and the first support claim line satisfy the requirements of the entry for the first claims processing rule, at least one of (a) creating, via the one or more processors, a case for the current claim line based at least in part on the first support claim line irrespective of the first claims processing rule, even though applying the first claims processing rule would not create a case for the current claim line based at least in part on the first support claim line, or (b) considering, via the one or more processors, the current claim line further for creating a case based at least in part on the first support claim line irrespective of the first claims processing rule. |
