Patents Assigned to The TriZetto Group, Inc.
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Patent number: 8494876Abstract: 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.Type: GrantFiled: January 12, 2012Date of Patent: July 23, 2013Assignee: The TriZetto Group, Inc.Inventors: Sherwood Chapman, J. Mikel Echeverria
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Publication number: 20130151282Abstract: 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.Type: ApplicationFiled: February 6, 2013Publication date: June 13, 2013Applicant: THE TRIZETTO GROUP, INC.Inventor: THE TRIZETTO GROUP, INC.
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Publication number: 20130144648Abstract: 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.Type: ApplicationFiled: December 10, 2012Publication date: June 6, 2013Applicant: The TriZetto Group, Inc.Inventor: The TriZetto Group, Inc.
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Patent number: 8457981Abstract: 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.Type: GrantFiled: December 3, 2003Date of Patent: June 4, 2013Assignee: The TriZetto Group, Inc.Inventor: Roy Schoenberg
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Patent number: 8407071Abstract: 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.Type: GrantFiled: January 18, 2012Date of Patent: March 26, 2013Assignee: The TriZetto Group, Inc.Inventors: Mark Lesswing, Dale Hoerle
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Patent number: 8271298Abstract: 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.Type: GrantFiled: December 13, 2011Date of Patent: September 18, 2012Assignee: The TriZetto Group, Inc.Inventors: Manon S. Ruben, Richard Lieberman
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Patent number: 8214230Abstract: 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.Type: GrantFiled: October 9, 2009Date of Patent: July 3, 2012Assignee: The TriZetto Group, Inc.Inventors: Albert R. DiPiero, David G. Sanders
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Publication number: 20120109681Abstract: 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.Type: ApplicationFiled: January 12, 2012Publication date: May 3, 2012Applicant: THE TRIZETTO GROUP, INC.Inventors: Sherwood Chapman, J. Mikel Echeverria
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Patent number: 8160905Abstract: 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.Type: GrantFiled: December 22, 2010Date of Patent: April 17, 2012Assignee: The TriZetto Group, Inc.Inventors: Mark Lesswing, Dale Hoerle
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Patent number: 8155977Abstract: 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.Type: GrantFiled: April 15, 2004Date of Patent: April 10, 2012Assignee: The TriZetto Group, Inc.Inventor: Roy Schoenberg
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Patent number: 8099302Abstract: 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.Type: GrantFiled: March 16, 2011Date of Patent: January 17, 2012Assignee: The TriZetto Group, Inc.Inventors: Sherwood Chapman, J. Mikel Echeverria
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Patent number: 8099736Abstract: 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.Type: GrantFiled: October 14, 2004Date of Patent: January 17, 2012Assignee: The TriZetto Group, Inc.Inventors: Dale E. Hoerle, Jeffery K. Hensley
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Patent number: 8099306Abstract: 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.Type: GrantFiled: February 6, 2008Date of Patent: January 17, 2012Assignee: The TriZetto Group, Inc.Inventors: Manon S. Ruben, Richard Lieberman
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Publication number: 20110257995Abstract: 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.Type: ApplicationFiled: June 28, 2011Publication date: October 20, 2011Applicant: The TriZetto Group, Inc.Inventor: Val C. Dean
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Patent number: 7979283Abstract: 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.Type: GrantFiled: December 27, 2004Date of Patent: July 12, 2011Assignee: The TriZetto Group, Inc.Inventor: Val C. Dean
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Patent number: 7827562Abstract: 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.Type: GrantFiled: June 16, 2005Date of Patent: November 2, 2010Assignee: The TriZetto Group, Inc.Inventors: Dale E. Hoerle, Jeffery K. Hensley
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Patent number: 7774377Abstract: 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.Type: GrantFiled: December 3, 2003Date of Patent: August 10, 2010Assignee: The TriZetto Group, Inc.Inventor: Roy Schoenberg
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Patent number: 7747850Abstract: A system and method are disclosed for managing bi-directional authentication among two or more users comprising at least one server which distributes security protocol information. The security protocol information may include digital certificates which permit authentication of users. The system and method allow for distribution of security protocol information regarding multiple users to multiple selected users directly from the server. Thus, users do not need to exchange information individually among themselves. The distribution of information may include updates, such as the addition of a new user or the change in the status or protocol information of an existing user. New users with proper privileges may receive protocol information for multiple existing users from a single source.Type: GrantFiled: November 2, 2005Date of Patent: June 29, 2010Assignee: The TriZetto Group, Inc.Inventors: Michael E. Gordon, Sheryl J. Adam, James M. Cavanaugh, James D. Osburn
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Patent number: 7624026Abstract: 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.Type: GrantFiled: November 21, 2001Date of Patent: November 24, 2009Assignee: The TriZetto Group, Inc.Inventors: Albert R. DiPiero, David G. Sanders
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Publication number: 20090198517Abstract: 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.Type: ApplicationFiled: February 6, 2008Publication date: August 6, 2009Applicant: The TriZetto Group, Inc.Inventors: Manon S. Ruben, Richard Lieberman