| 摘要 |
A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes referencing an integrated transaction including a number of clinical data elements, wherein the clinical data elements include clinical event details and electronic medical record data elements associated with a patient. Clinical data elements are used to select medical appropriateness criteria from an appropriateness knowledge base. Thereafter, it is determined that an electronic medical record data element affects the selected medical appropriateness criteria. As a result, the medical appropriateness criteria is adjusted in accordance with the electronic medical record data elements determined to affect the medical appropriateness criteria. The adjusted medical appropriateness criteria is used to determine whether the clinical data element(s) satisfy the adjusted medical appropriateness criteria. |
