Abstract: A system supporting one or more Internet-of-Things (IoT) applications for enabling repeatable use cases includes a reference architecture and a toolkit including re-usable components. The re-usable components are selectable to support the one or more IoT applications to enable the repeatable use cases which require access to data from multiple individual devices accessible via a cloud platform.

Abstract: Enhanced methods for providing software support and resolving software support issues are provided, particularly those related to an entity, including a specific entity in a database. A method selects an entity, such as a healthcare claim or other entity in a database, for which there is a software issue. The method then identifies all data and relationships relevant to that entity, including all related tables and data for that entity. The specific entity, data, and relationships are then exported. This method provides better, more efficient, and enhanced software support by exporting not only the identified entity, but all other relevant data and relationships to that entity, for analysis in resolving any software support issues.

Abstract: A system and process for prospectively creating patient episodes of care and triggering associated payment bundles during the claim adjudication process facilitates real-time claim pricing in accordance with payment bundle rules to facilitate episodic payment in place of pay-for-service payment. Additionally, various processes are described for modeling patient episodes and payment bundles and unbundling episodic payments.

Abstract: Systems and methods are provided in which contract terms from a first electronic representation of a contract are used to form at least a part of a second electronic representation of the contract. For instance, the first electronic representation of a contract may be formed for use with a first software application, such as an adjudication application, and such first electronic representation of the contract is used by a system to form at least part of a second electronic representation of the contract, wherein such second electronic representation is used by a second software application, such as a contract management application. Disparate applications often utilize different representations of contract terms, and certain embodiments enable a second electronic representation to be formed by the system at least in part from a first electronic representation so that the different electronic representations are consistent as to the overlapping contract terms included therein.

Abstract: Methods and systems for payment assurance and claim pre-validation are described. In one embodiment, a pre-visit claim for health care related services is received for payment assurance. In response to the pre-visit claim, a payer is queried for pre-visit claim detail information indicating any payment or authorization issues for services to be rendered. The pre-visit claim may be updated in certain embodiments based on the pre-visit claim detail information, and an appointment may be scheduled for services. In other aspects, a claim for health care related services is received for pre-validation. In response, a payer is queried for claim detail information indicating any payment or authorization issues for the claim. The claim may be updated in certain embodiments based on the claim detail information, and payment for services rendered may be provided by a payer in response to a submitted claim.

Abstract: Processes for estimating payment on a claim for services rendered are described. The process includes formatting data related to a medical service to be rendered to a patient in a mock claim, applying pricing rules that are unique to an agreement between payer entity and a provider of the service; and determining an estimated payment for the medical service to be paid by the payer to the provider after the medical service has been rendered to the patient.

Abstract: Deployment assurance services Accelerators (“DAS Accelerators”) include audit functionality that performs a sequential audit of each server listed in a customer's server list from customer's target environment. And artificial intelligence engine (“AI engine”) scans each server to match all required Include entries, which enables categories of product specific checks. Checks for each product category are processed sequentially, including database specific checks. All database platforms can be configured to connect on custom\nonstandard ports, using unique credentials. After each server audit is completed, the audit results are outputted to an encrypted file, a csv or database, depending on how the execution was configured by the customer. Audits review hardware, software, registry, integration and configuration details from customer servers for, e.g., the purpose of validating fitness for use. Various validation and environment reports are generated based on the audit results.

Abstract: The present invention is directed to a system and method which allows a prospective insured to make an informed decision on healthcare insurance or a specific health care management decision by using a current medical profile to assist in their selection. Based on past medical care, as obtained from payor data, a number of different plans, each having different providers, different deductibles, different maximums, different reimbursement policies, etc., a person can make an informed decision. When a family has different payors for different family members, a proper blend of payors can be more easily selected since the payors (or a single payor) has a medical profile of each family member and also has information on providers in the network, prescription policies, deductibles, maximums, etc.

Abstract: Systems and methods for managing a health plan are described. In one embodiment, a method for managing a health plan includes presenting options for a health plan and an incentive program of the health plan, presenting options for configuring a health plan and an incentive program of the health plan, and receiving a selection of an incentive program. In other aspects, the method further comprises receiving a selection of a health plan and an incentive program, storing information about the selected health plan and incentive program, storing information regarding participation in the incentive program, and requesting a reward for a member for completion of the incentive program. In other aspects, the method may further include determining eligibility for an incentive program and a reward of the incentive program.

Abstract: The present disclosure is directed to a system and method which gathers information from all of a person's healthcare providers and abstracts from that information the data necessary for a healthcare provider to render informed medical decisions. In one embodiment, information necessary to process proper payment to a provider (re: reimbursement to the insured patient) is used to develop a holistic view of the medical condition pertaining to the patient. Since this information comes from a myriad of providers, including physicians, surgeons, nursing care, druggists, testing labs, mental health counselors, dentists, oral surgeons, etc., the holistic view that is developed is comprehensive. In one embodiment, the system and method could set parameters on critical data such that if that data is outside the set parameters, alerts can be sent to the appropriate caregivers and/or patients.

Abstract: Methods and systems for payment assurance and claim pre-validation are described. In one embodiment, a pre-visit claim for health care related services is received for payment assurance. In response to the pre-visit claim, a payer is queried for pre-visit claim detail information indicating any payment or authorization issues for services to be rendered. The pre-visit claim may be updated in certain embodiments based on the pre-visit claim detail information, and an appointment may be scheduled for services. In other aspects, a claim for health care related services is received for pre-validation. In response, a payer is queried for claim detail information indicating any payment or authorization issues for the claim. The claim may be updated in certain embodiments based on the claim detail information, and payment for services rendered may be provided by a payer in response to a submitted claim.

Abstract: Disclosed is an integrated health plan computer system that enables on-line billing related transactions. The integrated health plan computer system may include a server to couple the integrated health plan computer system to a billing entity user through a network. A billing module operable with the integrated health plan computer system and the server is utilized to enable on-line billing related transactions for the billing entity user through the network. The billing module includes an invoice presentment module to perform invoice presentment transactions for the billing entity user and to display results of the invoice presentment transaction to the billing entity user. The billing entity user may be a group administrator, a broker, or an individual.

Abstract: Processes for estimating payment on a claim for services rendered are described. The process includes formatting data related to a medical service to be rendered to a patient in a mock claim, applying pricing rules that are unique to an agreement between payer entity and a provider of the service; and determining an estimated payment for the medical service to be paid by the payer to the provider after the medical service has been rendered to the patient.

Abstract: A data entry method includes, in a computer-based data record including a plurality of data fields, defining one or more data fields for which desired field data is to be acquired. A data source in possession of the desired field data is contacted, and the desired field data is received from the data source.

Abstract: A system and process for prospectively creating patient episodes of care and triggering associated payment bundles during the claim adjudication process facilitates real-time claim pricing in accordance with payment bundle rules to facilitate episodic payment in place of pay-for-service payment. Additionally, various processes are described for modeling patient episodes and payment bundles and unbundling episodic payments.

Abstract: Methods and systems for payment assurance and claim pre-validation are described. In one embodiment, a pre-visit claim for health care related services is received for payment assurance. In response to the pre-visit claim, a payer is queried for pre-visit claim detail information indicating any payment or authorization issues for services to be rendered. The pre-visit claim may be updated in certain embodiments based on the pre-visit claim detail information, and an appointment may be scheduled for services. In other aspects, a claim for health care related services is received for pre-validation. In response, a payer is queried for claim detail information indicating any payment or authorization issues for the claim. The claim may be updated in certain embodiments based on the claim detail information, and payment for services rendered may be provided by a payer in response to a submitted claim.

Abstract: Processes for estimating payment on a claim for services rendered are described. The process includes formatting data related to a medical service to be rendered to a patient in a mock claim, applying pricing rules that are unique to an agreement between payer entity and a provider of the service; and determining an estimated payment for the medical service to be paid by the payer to the provider after the medical service has been rendered to the patient.

Abstract: A method of adjudicating a medical claim includes providing a requirements for a first claim and a second claim, receiving a medical claim for a medical procedure, setting a first score for the first claim and a second score for the second claim to an initial value, comparing components of the medical claim to the requirements of the first and second claims, changing the first and second scores for each one of the components that match one of the requirements and for each one of the requirements that is missing from the components, and selecting the first or second claim based upon predetermined criteria applied to their respective scores to determine either a monetary value of the medical procedure for a medical service provider associated with the medical procedure or a monetary value of medical coverage for a patient associated with the medical procedure.

Abstract: A system and process for prospectively creating patient episodes of care and triggering associated payment bundles during the claim adjudication process facilitates real-time claim pricing in accordance with payment bundle rules to facilitate episodic payment in place of pay-for-service payment. Additionally, various processes are described for modeling patient episodes and payment bundles and unbundling episodic payments.

Abstract: A processor-driven method provides a step-by-step process to assess an organization's ability to meet project and contract standards resulting from a negotiated contract. This assessment also highlights the most efficient path for performance and identifies strengths and weaknesses in the organizations abilities. The method can aid an organization's front line sale force in identifying resources that are optimal for use in a particular contract and can generate a back end work flow for implementation and tracking of program deliverables by administrators, program or contract managers and others based on the requirements of a negotiated project. The identification of key project phases and solutions and the ability to build process flows based on a library of the organization's operational information, e.g., resources, tools, artifacts, within intersections of the phases and solutions, allows an organization to determine best path to contract completion. The best path may optimize cost, time, and personnel.