Electronic creation, submission, adjudication, and payment of health insurance claims

Claim 2

A method for submitting and adjudicating claims as recited in claim 1 , further comprising, prior to transmitting said claim for adjudication, the steps of: modifying, using the access terminal, the information in the claim in order to change the adjudication status of the claim; and then re-testing the adjudication status of the claim.

Claim 3

A method for submitting and adjudicating claims as recited in claim 1 , further comprising, if the claim is to be paid automatically, the step of initiating payment of the claim by the automated payment component by transmitting information that ultimately results in an electronic transfer of finds to said health care provider.

Claim 4

A method for submitting and adjudicating claims as recited in claim 1 , further comprising the step of forwarding the claim to a claims processing location for adjudication and payment if the claim is to be manually adjudicated by the adjudicator.

Claim 5

A method for submitting and adjudicating claims as recited in claim 1 , further comprising the steps of: determining the parties responsible for payment of the claim; and forwarding, from the automated adjudication component to at least one of said parties, a request for electronic payment of a first portion of the claim and forwarding, from the automated adjudication component to at least another of said parties, a printed invoice for payment of a second portion of the claim.

Claim 6

A method for submitting and adjudicating claims as recited in claim 1 , further comprising the step of the automated adjudication component producing an explanation of benefits identifying the treatment provided and the ultimate disposition of the claim, including the amount paid by each party responsible for payment.

Claim 7

In a system comprising a health care benefit component that stores patient and benefit information and allows access to stored information by a health care provider, an automated adjudication component that automatically adjudicates claims submitted for payment, an automated payment component that automatically pays adjudicated claims, payment tracking component that tracks the status of claims submitted for automatic payment, and an access terminal associated with the health care provider, a method for submitting and adjudicating claims comprising the steps of: accessing, using the access terminal, the patient and benefit information stored by the health care benefit component such that the health care provider can ascertain patient information in preparation for submitting a claim for treatment provided to a patient; creating, using the access terminal, the claim by entering information regarding treatment provided to said patient into an electronic claim form that can be submitted for payment; testing the adjudication status of said claim so that before said claim is submitted for adjudication, said health care provider may learns that, without modification of the claim, the claim is to be manually adjudicated by an adjudicator as opposed to being automatically adjudicated; receiving, using the access terminal, input modifying said claim in order to change the adjudication status of said claim; re-testing the adjudication status of the modified claim so that before said modified claim is submitted for adjudication, said health care provider learns that said modified claim is to be automatically adjudicated and how much said health care provider is to be paid; transmitting said modified claim from the access terminal to said automated adjudication component for automatic adjudication; and tracking the payment status of said modified claim by communicating with said payment tracking component using the access terminal.

Claim 8

A method for submitting and adjudicating claims as recited in claim 7 , further comprising the steps of: determining the parties responsible for payment of the claim; and forwarding, from the automated adjudication component to at least one of said parties, a request for electronic payment of a first portion of the claim and forwarding, from the automated adjudication component to at least another of said parties, a printed invoice for payment of a second portion of the claim.

Claim 9

A method for submitting and adjudicating claims as recited in claim 7 , further comprising the step of the automated adjudication component producing an explanation of benefits identifying the treatment provided and the ultimate disposition of the claim, including the amount paid by each party responsible for payment.

Claim 10

In an environment wherein a patient visits a health care provider for the purpose of receiving treatment and wherein the health care provider submits claims for payment for provided treatment to a payor who is responsible for paying at least a portion of the treatment costs, a system for providing health benefit information to the health care provider and for interactively adjudicating claims for payment and for making automated payment of adjudicated claims comprising: means for storing health benefit information comprising (1) patient identifying information to identify a patient and (2) health benefit information that allows a health care provider to determine benefit coverage for said patent; means for said health care provider to access said health benefit information in order to ascertain the benefit status of said patient prior to treatment of said patient; means for said health care provider to electronically generate a claim for payment for treatment provided to said patient; means for said health care provider to determine the adjudication status of said claim, so that before said claim is submitted for adjudication, said health care provider knows whether said claim is to be manually adjudicated by an adjudicator or whether said claim is to be automatically adjudicated; and means for electronically submitting said claim for adjudicating.

Claim 11

A system as recited in claim 10 , further comprising means for sending claims that are to be manually adjudicated to an entity for manual adjudication.

Claim 12

A system as recited in claim 10 , further comprising means for enabling the health care provider to track the payment status of claims that have been submitted for adjudication.

Claim 13

A system as recited in claim 10 , further comprising means for initiating payment of adjudicated claims.

Claim 14

A system as recited in claim 13 , wherein said means for initiating payment comprises means for initiating electronic transfer of funds.

Claim 15

A system as recited in claim 13 , wherein said means for initiating payment comprises means for printing a paper invoice to be sent through the mail.

Claim 16

A system as recited in claim 10 , further comprising means for sending an explanation of benefits that describes the treatment provided, the amount to be paid for the treatment, and the party responsible for payment.

Claim 17

A system as recited in claim 10 , wherein said means for said health care provider to determine the adjudication status comprises a database describing the benefits available and the contractual obligations of said payor to pay said health care provider for treatment rendered.

Claim 18

A system as recited in claim 10 , wherein the means for said health are provider to generate a claim further comprise means for enabling the health care provider to modify said claim in order to change the adjudication status of said claim prior to submission of the claim for adjudication.

Claim 19

In an environment wherein a patient visits a health care provider for the purpose of receiving treatment and wherein the health care provider submits claims for payment for provided treatment to a payor who is responsible for paying at least a portion of the treatment costs, a system for providing health benefit information to the health care provider and for interactively adjudicating claims for payment and for making automated payment of adjudicated claims comprising: means for storing health benefit information comprising (1) patient identifying information to identify a patient and (2) health benefit information that allows a health care provider to determine benefit coverage for said patent; means for said health care provider to access said health benefit information in order to ascertain the benefit status of said patient prior to treatment of said patient; means for said health care provider to electronically generate a claim for payment for treatment provided to said patient; means for said health care provider to determine the adjudication status of said claim, so that before said claim is submitted for adjudication, said health care provider knows whether said claim is to be manually adjudicated by an adjudicator or whether said claim is to be automatically adjudicated; and means for modifying said claim prior to submitting the claim for adjudication in order to change the adjudication status of said claim if it is otherwise determined that the claim is to be manually adjudicated; means for electronically submitting said claim for adjudicating; and means for enabling the health care provider to track the payment status of claims that have been submitted for adjudication.

Claim 20

A system as recited in claim 21 , further comprising means for sending claims that are to be manually adjudicated to an entity for manual adjudication.

Claim 21

A system as recited in claim 20 , wherein said means for said health care provider to determine the adjudication status utilizes custom rules provided by the payor to determine whether said claim is to be automatically adjudicated or manually adjudicated.

Claim 22

A system as recited in claim 21 , further comprising means for initiating payment of adjudicated claims.

Claim 23

A system as recited in claim 22 wherein said means for initiating payment comprises means for initiating electronic transfer of funds.

Claim 24

A system as recited in claim 23 , wherein said means for initiating payment comprises means for printing a paper invoice to be sent through the mail.

Claim 25

A system as recited in claim 24 , further comprising means for sending an explanation of benefits that describes the treatment provided, the amount to be paid for the treatment, and the party responsible for payment.

Claim 26

A system as recited in claim 25 , wherein said means for said health care provider to determine the adjudication status comprises a database describing the benefits available and the contractual obligations of said payor to pay said health care provider for treatment rendered.

Claim 27

In an environment wherein a patient visits a health care provider for the purpose of receiving treatment and wherein the health care provider submits claims for payment for provided treatment to a payor who is responsible for paying at least a portion of the treatment costs, a system for providing health benefit information to the health care provider and for interactively adjudicating claims for payment and for making automated payment of adjudicated claims comprising: a health benefit system adapted to allow electronic access to patient and benefit information, comprising: a benefit database comprising patient information which identifies individuals eligible for benefits, benefit information which identifies the benefits available in sufficient detail to allow health care professionals and other individuals to determine, for each potential patient, particular covered or uncovered benefits, and health care provider information that allows potential patients to identify particular health care providers that can be used to receive treatment covered by the benefits; a benefit entry and modification module that allows entry and modification of said patient and benefit information; and a database access module that allows access to the information stored in the benefit database from locations remote to the benefit database; a health care claim entry system comprising: a claim entry module that allows a health care professional to enter information regarding treatment provided to a patient in order to create a claim that can be submitted for payment; a claim modification module that allows the health care professional to modify information in a claim prior to submission of the claim for adjudication and payment; a claim adjudication status module that allows the health care professional to check the adjudication status of a claim prior to submission of the claim for adjudication so as to learn at least (1) whether the claim, if submitted for adjudication, is to be adjudicated manually by an adjudicator or adjudicated automatically, and (2) if a claim is to be adjudicated automatically, the amount of payment that is to be received for the claim; and a claim submission module that submits a claim for processing; and an automated claims adjudication system comprising: a claim adjudication status check module that receives a request to test the adjudication status of a claim and returns, in response to the request, the adjudication status including at least (1) whether the claim, if submitted for adjudication, is to be adjudicated manually by an adjudicator or adjudicated automatically, and (2) if a claim is to be adjudicated automatically, the amount of payment that is to be received for the claim; and a claim processing module that receives submitted claims, determines whether the claim is to be adjudicated manually by and adjudicator or adjudicated automatically and (1) if the claim is to be adjudicated manually, sending the claim to the appropriate location for manual adjudication and (2) if the claim is to be adjudicated automatically, determining the amount of payment that should be made for the claim, determining the source of the payment, and then initiating payment of the claim.