Abstract: A healthcare insurance claim that includes variables characterizing aspects of a healthcare service for which reimbursement is sought is analyzed in order to determine whether there are any aspects that are indicative of fraud or error. This analysis includes generating score variables from the variables of the healthcare insurance claim and determining whether a presence of one or more of the pairs of variables is indicative of fraud or error based on levels of co-occurrence of the one or more pairs in historical healthcare insurance claims. If a positive determination occurs, then the healthcare insurance claim can be flagged or elevated for review by a user. Related techniques, apparatus, systems, and articles are also described.

Abstract: A computer-implemented approach for processing benefits payment claims for prescription medicine, with these operations. Receiving pending pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim specifying a patient. For each claim and its specified patient, performing operations including the following. Performing computer-driven statistical analysis of predefined aspects of one of the following in relation to a compiled history of past claims paid by one or more pharmacy benefits claims payors: claims history for the patient, the claim, medical history of the patient. Generating an indicator of predicted legitimacy by scoring results of the statistical analysis. Providing an output of at least one of the following: the indicator, payment advice prepared by applying predefined criteria to data including the indicator.