Systems and methods for evaluating healthcare claim transactions for medicare eligibility

摘要

Systems and methods for evaluating healthcare claim transactions for Medicare eligibility are described. A healthcare claim transaction designating a payor other than a Medicare Part B payor may be received from a healthcare provider computer, and a product or service associated with the transaction may be identified as a product or service that is eligible for Medicare Part B coverage. Based at least in part on the identification, a determination may be made as to whether a patient associated with the transaction is eligible for Medicare Part B coverage. The transaction may be routed to a claims processor computer if it is determined that the patient is not eligible for Medicare Part B coverage. However, if it is determined that the patient is eligible for Medicare Part B coverage, then a message indicating that the transaction is rejected may be communicated to the healthcare provider computer.

主权项

1. A computer-implemented method, comprising:
receiving, from a healthcare provider computer by a service provider system comprising one or more computers, a healthcare claim transaction for a patient, wherein the healthcare claim transaction is associated with a product or service and comprises payor information that designates a payor for the healthcare claim transaction that is not classified as a Medicare Part B payor; identifying, by the service provider system, that the product or service is eligible for Medicare Part B coverage; determining, by the service provider system and responsive to identifying that the product or service is eligible for Medicare Part B coverage, whether the patient is eligible for Medicare Part B coverage; and routing, by the service provider system, the healthcare claim transaction to a claims processor computer associated with the designated payor responsive to a determination that the patient is not eligible for Medicare Part B coverage, or communicating, by the service provider system to the healthcare provider computer and responsive to a determination that the patient is eligible for Medicare Part B coverage, a message indicating that the healthcare claim transaction is rejected, wherein the message comprises an indication that the healthcare claim transaction is rejected because the payor designated by the payor information is an improper payor for the healthcare claim transaction.