Abstract: A claim pre-processing system employs trial adjudication to improve claim accuracy prior to claim submission to a healthcare payer institution or other entity. A system processes claim data related to provision of healthcare to a patient The system includes a claim data collator for collating data related to a claim for a particular patient for submission to a payer and a source of rules for use in processing collated claim data. A pre-processor submits the collated claim data for processing using the rules to validate the collated claim data is in condition for processing to initiate generation of payment. A claim processor submits the collated claim data to a payer, in response to successful validation by the pre-processor. A rules processor processes acquired claim data to identify a condition triggering application of a different set of rules for determining validity of an individual claim element.

Abstract: A patient claim data processing system responds to and initiates clinical events and attains early accurate claim data during a patient healthcare encounter cycle to support prompt claim data validation and editing both for individual claim elements and for a completed claim to improve claim accuracy prior to claim submission to a payer. The system submits accurate claims to payers and receives remittance advice from payers and applies rules to the advice. A system processes financial data related to provision of healthcare to a patient in response to clinical events. The system includes an interface processor for receiving a message identifying an event and a related change in healthcare data concerning a patient and also includes a source of rules for determining characteristics associated with reimbursement for provision of an individual service to a patient.

Abstract: A system monitors in real-time multiple organization patient healthcare financial and clinical encounter related information by automatically recognizing and evaluating complex data patterns to identify statistically significant patterns and clusters using user created data pattern templates to detect fraud, disease outbreaks and cost reduction opportunities. A system monitors healthcare encounter related information derived from patient interaction with a healthcare provider to detect irregular data patterns. The system includes an interface processor for receiving patient encounter related information comprising clinical and financial information from a plurality of different sources for storage in a database. A search processor searches the database to identify a predetermined data pattern and determines whether an identified data pattern meets predetermined criteria. A data processor processes the identified encounter related information to be suitable for output communication.

Abstract: A patient claim data processing system responds to and initiates clinical events and attains early accurate claim data during a patient healthcare encounter cycle to support prompt claim data validation and editing both for individual claim elements and for a completed claim to improve claim accuracy prior to claim submission to a payer. The system submits accurate claims to payers and receives remittance advice from payers and applies rules to the advice. A system processes financial data related to provision of healthcare to a patient in response to clinical events. The system includes an interface processor for receiving a message identifying an event and a related change in healthcare data concerning a patient and also includes a source of rules for determining characteristics associated with reimbursement for provision of an individual service to a patient.

Abstract: A centralized rules repository maintains consistently expressed rules used to process patient claim data in supporting medical procedure eligibility verification, patient referrals, treatment authorization, data entry editing, electronic claim submission, claim status determination and electronic remittance processing. A system for managing rules used for processing claim data related to provision of healthcare to a patient includes an interface processor for acquiring data representing rules from a plurality of different sources. The system includes a rules repository for accumulating data representing acquired rules and a rules processor for initiating application of a selected rule derived from the repository to process claim data in response to a received message. A result processor processes a result being derived by the application of the selected rule to the claim data for output. The interface processor also transforms acquired rules to a common syntax suitable for storage in the rules repository.

Abstract: A claim pre-processing system employs trial adjudication to improve claim accuracy prior to claim submission to a healthcare payer institution or other entity. A system processes claim data related to provision of healthcare to a patient The system includes a claim data collator for collating data related to a claim for a particular patient for submission to a payer and a source of rules for use in processing collated claim data. A pre-processor submits the collated claim data for processing using the rules to validate the collated claim data is in condition for processing to initiate generation of payment. A claim processor submits the collated claim data to a payer, in response to successful validation by the pre-processor. A rules processor processes acquired claim data to identify a condition triggering application of a different set of rules for determining validity of an individual claim element.

Abstract: A system uses aggregated healthcare encounter service, billing, and claim data to enable an authorized patient to access healthcare encounter related information. A system supports patient access to healthcare encounter related information including information concerning an event involving interaction of a patient with a healthcare enterprise. The system includes an interface processor for receiving patient identification information and a request for encounter related information. The system also includes a database linking a patient identifier with, a record identifying at least one patient encounter and data identifying at least one healthcare provider organization associated with the at least one patient encounter and a record containing encounter information related to the at least one patient encounter.