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 reference architecture embodies a common, consistent, known best practice base reference architecture and configuration that may then be used for cloning out for the base of every customer environment. Given this base, the service provider is able to control the full functionality solution layer to provide the platform for consistent monitoring, patching, upgrading, etc. Accordingly, the service provider's application solution is an integrated appliance that can contain whatever is necessary at the solution layer to allow the service provider to remotely (or within the hosting center) support, maintain and gather key system metrics to promote optimal customer performance, decrease cost of implementation/support/ownership and vastly increase service offering base.

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 method for repricing a reimbursement claim under at least one contract is provided herein. The method may include a combination of steps such as: converting each contract into a series of contractual terms; converting a claim into a series of claim lines, containing claim codes, unit numbers and corresponding charges for the claim codes; comparing claim codes and contractual terms and identifying matches therebetween; determining any priority conditions associated to the matching contractual terms, and eliminate any matching contractual terms that are excluded by the priority conditions; calculating the reimbursement amount for the claim by determining the reimbursement charges for the non-excluded matching contractual terms; and determining and making any adjustments depending upon any discount terms for the entire reimbursement amount.

Abstract: A compliance process provides the ability to identify members that have completed a required activity for a Health Incentive Program (HIP) by comparing standard data such as claims, pharmacy, laboratory, biometric, health risk assessment and other pertinent internal and external data (hereafter “source data”) against established compliance criteria for that type of data for the specific HIP. If the member meets all compliance criteria within the designated timeframe, the member's achievement is recorded, resulting in the appropriate reward being granted as defined by the HIP. The compliance process solution provides an automated way for a payer to evaluate internal and/or external data including claims, pharmacy and/or biometric data to identify instances of a member completing required activities.

Abstract: A key organization method and system includes receiving a first access key that grants a patient-defined level of access to a first set of medical records, receiving a second access key that grants a patient-defined level of access to a second set of medical records, and storing the first and second access keys in a centralized key repository.

Abstract: A method for repricing a reimbursement claim under at least one contract is provided herein. The method may include a combination of steps such as: converting each contract into a series of contractual terms; converting a claim into a series of claim lines, containing claim codes, unit numbers and corresponding charges for the claim codes; comparing claim codes and contractual terms and identifying matches therebetween; determining any priority conditions associated to the matching contractual terms, and eliminate any matching contractual terms that are excluded by the priority conditions; calculating the reimbursement amount for the claim by determining the reimbursement charges for the non-excluded matching contractual terms; and determining and making any adjustments depending upon any discount terms for the entire reimbursement amount.

Abstract: Grouping, categorizing, and profiling pharmaceutical claims data to assist health care managers is described. In aspects, a method is described including receiving pharmacy claims data records, validating each of the claims data records for a valid drug code, establishing a number of validated pharmacy claims data records received for each drug identified, grouping the validated pharmacy claims data records to one or more pharmacy episodes, categorizing each pharmacy episode, and storing the validated pharmacy claims data records and associated pharmacy episodes for monitoring usage of prescription drugs. In various embodiments, a pharmacy episode group is a pharmacologically homogenous grouping of drugs with the same therapeutic ingredients used by a patient once or over an extended period of time, and pharmacy episodes are categorized based on algorithms linking the pattern of a physician's recommended use and the patient's pattern of compliance.

Abstract: Techniques and apparatus for managing contributions to an accruable health spending account in an employer-sponsored plan offering a member an employer-funded defined contribution, at least one insurance premium option and the ability to specify an allocation of the defined contribution for payment of option premiums and, in turn, a directed contribution amount designated to such accruable account are disclosed. The accruable account may be used to reimburse the member for qualified medical expenses, and the member may pay any premium shortfall using a tax-advantaged process such as a premium only payment plan. Also disclosed are techniques and apparatus directed to presenting member-specific out-of-pocket expenses for a selected procedure offered by at least one health-care provider.

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 method for repricing a reimbursement claim under at least one contract is provided herein. The method includes converting each contract into a series of contractual terms, where each contractual terms contains qualification codes, calculation codes and priority notes. The method then converts a claim into a series of claim lines, containing claim codes, unit numbers and corresponding charges for the claim codes. The method then begins to compare comparing each claim code, of the claim, against each qualification code, of each contractual term, of a contract and when a qualification code, of a contractual term, is satisfied by a claim code, of a claim line, the method identifies the contractual term as a matching contractual term associated to the claim line.

Abstract: A rule processing method includes defining a target group of patients chosen from a group of existing patients. An action to be taken concerning one or more patients within the target group of patients is defined, and an execution time for the action is scheduled.

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 computer-implemented method for grouping, categorizing, and profiling pharmaceutical claims data to assist health care managers in determining (a) medication treatment experience, outcomes, and medication compliance behaviors of patients and (b) appropriate drug prescribing, medication coordination, and cost-efficiency of health care providers. An objective means is provided for categorizing and quantifying patterns of prescription drug utilization as a health care service within a clinically relevant time frame. A pharmacy episode group (PEG) is a pharmacologically homogenous grouping of drugs with the same therapeutic ingredients used by a patient once or over an extended period of time. The PEG is a patient-centered pharmacy classification unit, which uses script-level pharmacy claim data as input data and assigns each script to the appropriate episode.

Abstract: Disclosed are systems and methods which provide an interface for software applications which provides intelligent routing of data between the software applications. Embodiments provide an interface between software applications using multiple adapters, wherein at least one adapter is associated with each end of a software application information communication link. Information communicated between software applications is routed based upon analysis of the information and/or associated transactions to provide dynamic interfacing between software applications. Information may be routed based upon content, transaction type, historical information, etcetera. Routing of information of embodiments establishes an itinerary for scheduling communication of information between a plurality of software applications.

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: 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: A method for repricing a reimbursement claim under at least one contract is provided herein. The method includes converting each contract into a series of contractual terms, where each contractual terms contains qualification codes, calculation codes and priority notes. The method than converts a claim into a series of claim lines, containing claim codes, unit numbers and corresponding charges for the claim codes. The method than begins to compare comparing each claim code, of the claim, against each qualification code, of each contractual term, of a contract and when a qualification code, of a contractual term, is satisfied by a claim code, of a claim line, the method identifies the contractual term as a matching contractual term associated to the claim line.

Abstract: A system and method are provided that enable flexible publishing and consumption of data between disparate applications. In one embodiment, a system comprises a first application and an adapter interfaced with the first application. The adapter is operable to publish data of the first application for consumption by another application, wherein the adapter publishes the data of the first application according to a publishing regime not natively supported by the first application. In certain embodiments, the adapter publishes data of an application in a plurality of different formats (e.g., database format, file format, messaging format), and consuming application(s) can then selectively access any of the plurality of different formats in which the data is published. In certain embodiments, a consumption log is maintained by an adapter that provides information concerning consumption of data by one or more consuming applications.

Abstract: A range-conversion method and system includes receiving data records. Each data record includes one or more data fields and a field value associated with each data field. One or more data fields are identified as a range-based data field. A plurality of text-based range descriptors are defined, such that each text-based range descriptor is associated with a range of field values for one of the range-based data fields.