| 摘要 |
An automated system for administering health care insurance claims utilizes a series of rules, including a hierarchal set of Super Rules, specific Client Rules and General Rules, to apply selected criteria to the parameters of each respective insurance claim. When the criteria of a rule filter is met by the specific insurance claim parameters, an action is applied to the claim, allowing the insurance claim to be resolved without manual negotiation of the claim. If the criteria of none of the rule filters are met, the default action is a manual negotiation of the insurance claim by the claims administrator who is provided with a monitor display containing the pertinent information needed to negotiate a settlement discount for the health care service provided. The automated system provides a filter template to facilitate the creates of new rules to be applied to the administration of an insurance claim. |
| 主权项 |
1. A method of processing health care claims corresponding to the receipt of services for a patient by a health care provider, comprising the steps of:
coding parameters of the health care claim; inputting the coded parameters of the health care claim into a computer; analyzing the parameters of the health care claim by applying a first set of rules to the parameters of the health care claim, each rule in said first set of rules including a filter and an action for application to the health care claim when the filter is matched to a corresponding parameter of the health care claim, said first set of rules being arranged in an order of priority such that each rule in said first set of rules is applied to the parameters of the health care claim in sequential order according to said order of priority; if the parameters of the health care claim match the filter of one of the rules in said first set of rules, then applying the action to the health care claim according to the action of the rule of said first set of rules having the matched filter; if none of the parameters of the health care claim match any of the filters of the rules of said first set of rules, then applying a second set of rules to the parameters of the health care claim, each rule in said second set of rules having a filter and an action for application to the health care claim when the filter of a rule in said second set of rules is matched to one of the parameters of the health care claim, each rule in said second set of rules being client specific; if one of the filters of said second set of rules is matched to one of the parameters of the health care claim, then applying the corresponding action associated with the rule of said second set of rules having the matched filter; and if none of the filters of the rules of the second set of rules matches one of the parameters of the health care claim, then designating the health care claim for manual negotiation. |
