Data-driven concepts for processing claims

Patent metadata

Field	Value
Publication number	US-2016140664-A1
Application number	US-201615008584-A
Country	US
Kind code	A1
Filing date	Jan 28, 2016
Priority date	Mar 30, 2012
Publication date	May 19, 2016
Grant date	—

Abstract

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 an inclusions table, an exclusions table, and/or a decision table as part of firing or executing claims processing rules to accommodate for such changes.

First claim

1 . A method for processing a claim, the method comprising:
processing a current claim line in accordance (a) with a first claims processing rule and (b) a first support claim line, 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 a processor, 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 indicates how to process the current claim line when the current claim line and a support claim line satisfy the requirements of the entry for the first claims processing rule; after determining, via the processor, that an entry exists in the table for the first claims processing rule, determining 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, via the processor, that the current claim line and the first support claim line satisfy the requirements of the entry for the first claims processing rule, determining how to process the current claim line based at least in part on the entry for the first claims processing rule irrespective of the first claims processing rule.

2 . The method of claim 1 , wherein determining how to process the current claim line based at least in part on the entry for the first claims processing rule comprises determining whether to (a) create a case for the current claim line based at least in part on the entry for the first claims processing rule or (b) exclude a case from being created for the current claim based at least in part on the entry for the first claims processing rule.

3 . The method of claim 1 further comprising processing the current claim line in accordance (a) with a second claims processing rule and (b) a second support claim line.

4 . The method of claim 3 further comprising determining whether an entry exists in the table for the second claims processing rule, wherein the entry for the second claims processing rule indicates how to process the current claim line when the current claim line and a support claim line satisfy the requirements of the entry for the second claims processing rule.

5 . The method of claim 4 further comprising:
after determining that an entry exists in the table for the second claims processing rule, determining whether the current claim line and the second support claim line satisfy the requirements of the entry for the second claims processing rule; and
after determining that the current claim line and the second support claim line satisfy the requirements of the entry for the second claims processing rule, determining how to process the current claim line based at least in part on the entry for the second claims processing rule.

6 . The method of claim 1 , wherein the current claim line and the first support claim line satisfy a history definition of the first claims processing rule.

7 . The method of claim 1 , wherein the current claim line, the first support claim line, and the second support claim line are from the same claim.

8 . The method of claim 1 further comprising receiving input creating the entry for the first claims processing rule in the table.

9 . A computer program product for processing a claim, the computer program product comprising at least one non-transitory computer-readable storage medium having computer-readable program code portions stored therein, the computer-readable program code portions comprising:
an executable portion configured to process a current claim line in accordance (a) with a first claims processing rule and (b) a first support claim line, 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; an executable portion configured to determine 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 indicates how to process the current claim line when the current claim line and a support claim line satisfy the requirements of the entry for the first claims processing rule; an executable portion configured to, after determining that an entry exists in the table for the first claims processing rule, determine whether the current claim line and the first support claim line satisfy the requirements of the entry for the first claims processing rule; and an executable portion configured to, 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, determining how to process the current claim line based at least in part on the entry for the first claims processing rule irrespective of the first claims processing rule.

10 . The computer program product of claim 9 , wherein determining how to process the current claim line based at least in part on the entry for the first claims processing rule comprises determining whether to (a) create a case for the current claim line based at least in part on the entry for the first claims processing rule or (b) exclude a case from being created for the current claim based at least in part on the entry for the first claims processing rule.

11 . The computer program product of claim 9 further comprising an executable portion configured to process the current claim line in accordance (a) with a second claims processing rule and (b) a second support claim line.

12 . The computer program product of claim 11 further comprising an executable portion configured to determine whether an entry exists in the table for the second claims processing rule, wherein the entry for the second claims processing rule indicates how to process the current claim line when the current claim line and a support claim line satisfy the requirements of the entry for the second claims processing rule.

13 . The computer program product of claim 12 further comprising:
an executable portion configured to, after determining that an entry exists in the table for the second claims processing rule, determine whether the current claim line and the second support claim line satisfy the requirements of the entry for the second claims processing rule; and
an executable portion configured to, after determining that the current claim line and the second support claim line satisfy the requirements of the entry for the second claims processing rule, determine how to process the current claim line based at least in part on the entry for the second claims processing rule.

14 . The computer program product of claim 9 , wherein the current claim line and the first support claim line satisfy a history definition of the first claims processing rule.

15 . The computer program product of claim 9 , wherein the current claim line, the first support claim line, and the second support claim line are from the same claim.

16 . The computer program product of claim 9 further comprising an executable portion configured to receive input creating the entry for the first claims processing rule in the table.

17 . An apparatus comprising at least one processor and at least one memory including computer program code, the at least one memory and the computer program code configured to, with the processor, cause the apparatus to at least:
process

Assignees

• Mckesson Financial Holdings

Inventors

• Weber Tracy Ann
• Sheldon David
• Vijayakumar Prasanth
• Williams Gregory

Classifications

• G06Q40/08 Primary

  Insurance · CPC title

• G06Q10/10

  Office automation; Time management · CPC title

• A41D13/015

  with shock-absorbing means (A41D13/05 takes precedence) · CPC title