Abstract: 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.

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 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: Enhanced systems and methods for processing of healthcare information are provided. According to one embodiment, a method comprises receiving, at a claim processing system that is operable to adjudicate a claim for payment from an insurer for services rendered to a healthcare consumer, a request for estimated healthcare payment information. The request may pertain to a service that has not been rendered to the healthcare consumer. The request for the estimated healthcare information may be received (e.g., electronically, such as via a web interface, and/or otherwise via a communication network, such as the Internet) from the healthcare consumer or from a healthcare service provider. The method further comprises processing the request by the claim processing system for determining the requested estimated healthcare payment information. The method further comprises communicating, from the claim processing system, a response to the request that includes the estimated healthcare payment information.

Abstract: A method for establishing certifiable patient informed consent for a medical procedure, where, in one embodiment, the patient interacts with a video training system until mastery of all required information is successfully achieved. Training techniques which permit elicitation of measurable behaviors from a patient as a guide to discerning the level of knowledge of the patient are utilized. Certification is only granted when the measurable behavior approximately coincide with the legal and medical standards for establishing informed consent. The system is capable of adapting to various medical procedures, as well as various patient attitudes and knowledge bases, while still maintaining a level of consistency throughout. In one embodiment, a minimum probability of understanding may be preset, and the training procedure will continue until the actual statistical probability of understanding is at least equal to the preset minimum.

Abstract: Disclosed are systems and methods which provide an interface for disparate software applications using an adapter associated with at least one application of a first type to interface the first application with multiple applications of a second type, each of which has an associated adapter. A first adapter may be associated with a first software application, such as a claim processing software application. The present invention may enable the first software application to interact with a plurality of different applications of a second type, such as a plurality of different types of case management software applications that may be implemented within an insurer's organization.

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 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 patent) 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: Disclosed are systems and methods which provide an interface for disparate software applications using a decentralized adapter architecture. 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. Adapters are adapted for proprietary data communication with one or more application and for data communication with other adapters using protocols common to each such adapter. Information communication provided between software applications using adapters may be provided in batch mode, in real-time mode, or in both batch and real-time modes. Adapters may be associated with an enterprise function or “business process” basis. Accordingly, a plurality of adapters may be utilized with respect to any particular software application. Likewise, a plurality of software applications may be associated with any particular adapter.

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: 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: Disclosed are systems and methods which provide for monitoring an interface for software applications, for logging transactions conducted using the interface, and/or validating the transactions performed. Embodiments utilize adapters which communicate with an adapter monitor to determine the status of the adapters and/or interfaces provided using the adapters. A monitoring tool may additionally or alternatively be used to provide reporting with respect to the status of the adapters and/or interfaces provided using the adapters.

Abstract: Disclosed are systems and methods which provide for monitoring an interface for software applications, for logging transactions conducted using the interface, and/or validating the transactions performed. Embodiments utilize adapters which communicate with an adapter monitor to determine the status of the adapters and/or interfaces provided using the adapters. A monitoring tool may additionally or alternatively be used to provide reporting with respect to the status of the adapters and/or interfaces provided using the adapters.