Abstract: Embodiments of various systems, methods, and devices are disclosed for generating artificial intelligence or machine learning models for predicting denials of medical claims, predicting approvals of resubmitted medical claims, as well as automatic workflow clustering processes for automatically assigning medical claims to workflow queues using predictive segmentation and smart resource allocation.

Abstract: Improved entity identification is provided. Reference data sourced from various data sources may be used to more accurately identify an individual to improve the ability for multiple transaction processing systems to more effectively match identities for the transmission, receipt, and linking of data records. Accordingly, various enterprises are enabled to communicate about a particular entity without each enterprise having the same identifier or having the same, accurate entity demographic information.

Abstract: Automated assistance program qualification and enrollment are provided. An assistance program qualification and enrollment (APQE) system determines whether a user qualifies for an assistance program that offers assistance with an ongoing transaction record with a service provider. The APQE system generates a set of questions based on qualification data (used to make a qualification determination) that are not included in collected user data and financial data about the user. The user's qualification is based on an evaluation of the user data, financial data, and user-provided responses to the questions. If the user qualifies for the assistance program, an option is provided to the user to enroll in the assistance program. If additional information is needed to complete an enrollment process for the assistance program, an interface is provided that enables the user to provide the data for completing the process.

Abstract: A preauthorization management system. The preauthorization management system allows a health care provider to submit a preauthorization request and track the status of the preauthorization request until a final determination is reached. Once a request has been submitted, the preauthorization management system monitors the status of the request until a final disposition is reached. The preauthorization management system documents the submission and determination process to provide a record that may be used to show an event or outcome occurred. The preauthorization management system offers a simplified and uniform system for managing preauthorization for health care services that reduces or eliminates the need for health care providers to learn diverse systems and procedures of a multitude of health insurance providers.

Abstract: Generating and providing match justifications in association with record matching results for improved record matching is provided. An entity resolution system generates a set of deterministic rules based on patterns of attribute comparison outcomes of known matched and unmatched records. Each rule includes matching conditions and an action instruction including a message of a justification for a match/non-match. The system receives a request to determine a match between two records. A matching engine compares various attributes of the records using probabilistic matching technologies to determine a match outcome. A justification engine compares attribute comparison outcomes to the stored rules. When the matching conditions of a rule are satisfied, the rule is activated and a human-readable justification is linked to the match output and provided in a match response. The justification provides insights into the match outcome, and improves the speed and accuracy of a verification process of the match output.

Abstract: Entity matching is provided. A request to determine a second entity matching with a first entity may be received. Demographic fields to be compared to determine the match may be determined. Comparison weights including an agreement weight, a disagreement weight, and a null weight may be assigned to each of the plurality of demographic fields. The received request may be parsed to determine demographic fields data related to the second entity. The demographic fields data may be compared with indexed demographic data which may include a plurality of records. The demographic fields data may be compared for the determined plurality of demographic fields. A comparison weight for each of the plurality of demographic fields may be determined based on the comparison. The first entity matching with the second entity may be determined from the indexed demographic data based on determined comparison weights for the plurality of demographic fields.

Abstract: Quantitative estimate accuracy scoring is provided. An estimate scoring engine uses estimate scoring model logic to quantitatively measure the accuracy of an estimate for healthcare services relative to actual values associated with an adjudication of a claim for the services. Scores are determined for various factors that impact estimate accuracy, and a total estimate accuracy score may be determined. A report may be generated and displayed in a user interface including information received and/or determined by the estimate scoring engine. A plurality of estimates may be evaluated, and the report may include a summary and details associated with the accuracy of a range of estimates. An accuracy rate associated with the range of estimates may be measured against the accuracy rate of other healthcare services providers, payers, and/or estimation models in an ‘apples-to-apples’ comparison. Accordingly, issues associated with estimate inaccuracies may be identified and addressed to improve estimate accuracy.

Abstract: A downtime registration service is discussed herein that enables client systems that rely on electronic record management systems to continue generating records during a downtime event for the electronic record management system without relying on a workaround that requires temporary identifiers or reentry of data. The downtime registration system improves the efficiency and accuracy of electronic systems because workarounds that involve using temporary identifiers, or reentering data collected during the downtime, increase the amount of work done and the chance for errors to be introduced into the records. The client systems are in communication with an outside facility providing advanced services, which track the records generated during normal operation (i.e., not downtime) so that new records created during downtime properly reuse existing record identifiers or assign new identifiers that correspond to the clients' record keeping policies.

Abstract: Improvements to the process of providing patient assistance to conform with prescribed courses of treatment are provided. Providing assistance based on patient-specific data is implemented via an assistance analyzer communicated with a processing clearinghouse, and the process of determining how to assist the patients in adhering to their courses of treatment at the time the prescription is filled, without the patient engaging in a separate process to apply for a discount. By applying the present disclosure, existing systems improve their sensitivity to patient need when providing time sensitive information, and may be configured to use fewer processing resources than before; improving the functionality of the systems themselves.

Abstract: Aspects of the disclosure track and monitor automated system events, user-initiated events, and outcomes associated with system events and user-initiated events for providing real-time or near real-time measurements and insights. According to examples, a system is provided that is operative or configured to collect specific events and associated data associated with events that occur within various systems and products. The data is captured, aggregated, and stored in in-memory data storage. Accordingly, the data can be represented and displayed in a dashboard interface in real-time or near real-time. Accordingly, inefficient polling, long-running queries, and scheduled tasks can be eliminated.

Abstract: Improved entity identification is provided. Reference data sourced from various data sources may be used to more accurately identify an individual to improve the ability for multiple transaction processing systems to more effectively match identities for the transmission, receipt, and linking of data records. Accordingly, various enterprises are enabled to communicate about a particular entity without each enterprise having the same identifier or having the same, accurate entity demographic information.

Abstract: Identifying and addressing an individual's socio-economic factors related to negative health outcomes for reducing the likelihood of negative health outcomes for the individual in the form of readmission rates, emergency department utilization, missed appointments/no-shows, etc., may be realized by employing aspects of the present disclosure. A social determinants of health (SDoH) system accesses and analyzes consumer marketing data associated with the individual, business data, and public transportation data held by various databases for identifying indicators of SDoH factors, determines an individual's propensity for SDoH factors, and determines an engagement strategy to address SDoH that impact the individual. The results may be included in a report or included in a user interface that is transmitted to the requestor. The results may be displayed in a way that enables the requestor to easily identify and act on the individual's SDoH using recommended engagement strategies.

Abstract: Reductions to bandwidth storage resource use needed to safely and securely provide longitudinal data related to individuals to authorized parties from disparate sources are realized by employing the present disclosure. As the data related to the individual are held by various originating and aggregating databases in a variety of formats, with each database having different sharing policies, and the user similarly specifying different access permissions to personal data, a hub that manages access in a hybrid distributed/aggregated mode enables requestors to review data at a single point of access in accordance with specified access permissions from the databases or the individual. Reduced weight records, using permitted data fields, are aggregated and links to the records are provided according to the determined permission levels.

Abstract: A request for a most reliable demographic fields data for a selected demographic field associated with an entity may be received at an entity matching system. A plurality of records associated with the entity may be received at the entity matching system. Each of the plurality of records may include at least one demographic field. A demographic field corresponding to the selected demographic field may be identified from the at least one demographic field for each of the plurality of records. A reliability score may be determined for the corresponding demographic field for each of the plurality of records. The corresponding demographic field with the highest reliability score may be determined as the most reliable demographic fields data.

Abstract: Expanded data processing for entity matching is provided. A request for determining a matching entity is received. The received request is parsed to determine demographic field data associated with the request. A first look up operation is performed in an indexed demographic data for a first demographic field associated with the request. A first list of entities matching with the first demographic field data is received in response to the first look up operation. A second look up operation is performed in the indexed demographic data to determine a set of demographic attributes associated with each entity on the first list. The demographic attributes correspond to a second demographic field associated with the request. A matching confidence for whether the entity is associated with a given entity in the first list is determined based on a comparison between the demographic field data and the demographic attributes.

Abstract: An identity management method includes comparing person-to-person relationship data of at least two identifiers of individuals to determine if the at least two identifiers have a relationship with a common third party identifier. The person-to-person relationship data is obtained from one or more sources and the at least two identifiers are the same or similar. When it is determined that the at least two identifiers have a relationship with a common third party identifier, the method further includes generating an output indicating that the at least two identifiers actually identify the same individual. The output can alternatively, or further, include a confidence level indicative of the confidence that the at least two identities do indeed identify the same individual. The person-to-person relationship analysis can be combined with other forms of identity matching, e.g., demographics.

Abstract: Tracking the process of a client activity via an electronic system involves the provision of user interfaces by which data are communicated to user. Optimizing the generation of these user interfaces in a cloud-based system reduces processing resources required by the cloud-based portion, improves the user experience on the local portions, and improves the data collected by users. Using, as described herein, historical data known to the cloud-based portion related to both the user and the client, the user interfaces are updated to show progress of the activity and to organize the tasks for the given user in an optimal arrangement. Reports may also be generated regarding the efficacy of the users in shepherding the activity to completion in a more efficient manner. Various user interface elements are integrated into the cloud-based system for quick provision of activity and task statuses to the user.

Abstract: Aspects include a system that provides an end to end, digital self-registration experience to significantly limit and/or eliminate the time a user must spend in a registrar or waiting area checking in and filling out paperwork prior to a scheduled appointment, while also increasing accuracy of the user information obtained. For example, once an appointment has been scheduled for the user, the system may generate and transmit a push notification, such as a text message, to the user's device. The text message may include a selectable link directing the user to an application that guides the user seamlessly through a self-registration process. The self-registration process includes, among other steps, identity verification, payer verification, provision of demographic information, appointment confirmation, and post-confirmation steps (e.g., form completion, reminders, and day of appointment instructions and directions).

Abstract: An assembly management system allows a software service provider (SSP) to compile and upload client-specific client application code into a repository. The SSP deploys a client application comprising non-client-specific code to various clients. When a user logs in, a call is made to a web service, which queries the repository for code specific to the requesting client. If available, the web service sends a response with the name and version of the assembly to which the client is subscribed. If the locally-saved version does not match the version of the assembly in the repository, and if the SSP has permission to write to the client's disk, the web service retrieves the assembly and commits it to the disk. If the SSP does not have permission, the assembly is streamed to the client device and retained and executed in memory for the duration of the login.

Abstract: Aspects include a pre-service optimization system that provides timely and accurate estimate information to clients. Responsive to an indication of an order for a service, the system may generate an estimate of service costs, including the client responsibility amount, generate an elasticity estimate corresponding to the estimate including an indication of how likely the estimate is to change, a range within which the estimate is likely to change, and information about trigger points that affect the possible variability of the estimate. The system may push a notification to the client that includes a link to access the estimate and elasticity estimate. The notification may be delivered to the client in real time or near-real time as the estimate is generated. The system may further provide a user interface via which the client can access the estimate and elasticity estimate, and to access scheduling, payment, and financial assistance functionalities.