HEALTH CARE PAYMENT AND COMPLIANCE SYSTEM

摘要

A system, method, and computer program product for health care payment and compliance are described herein. The system, method, and computer program product facilitate compliance with rules governing coverage by a third party payor for health care provided to a beneficiary by a provider. Compliance with the rules is aimed at simplifying and accelerating the process of providing health care to beneficiaries and insuring reimbursement to providers by third party payors. A third party payor provides its rules governing health care coverage to the system of the present invention. A beneficiary then orders from a provider a health care product or service which is administered under the medical benefit. The system then applies the provided coverage rules to determine the level of coverage by the third party payor for the order. Based on this determination, the provider can automatically bill the third party payor for the portion of the value of the order covered by the third party payor. Upon application of the provided coverage rules, the system converts the product codes submitted by the provider to more specific product codes. The converted product codes are then provided to the third party payor. The system can be applied to ancillary health care administered under the medical benefit.