Abstract: Systems and process for performing analytical processes on the health-related data for a person include components and steps for processing system multiple files from multiple sources containing health-related data for numerous individual. Such processing may include: staging health-related data; matching pieces of staged data to a person using one or more matching rules; compressing the matched staged data for the person into a compressed file through assignment of a universal identifier which is associated with the person; providing the compressed file to an analytics engine; and decompressing the at least one analytics results file using universal identifier to access the analytics results for the person. Additionally, the analytics results for the person may be provided to a user for intervention into the health of the person.

Abstract: Systems and process for performing analytical processes on the health-related data for a person include components and steps for processing system multiple files from multiple sources containing health-related data for numerous individual. Such processing may include: staging health-related data; matching pieces of staged data to a person using one or more matching rules; compressing the matched staged data for the person into a compressed file through assignment of a universal identifier which is associated with the person; providing the compressed file to an analytics engine; and decompressing the at least one analytics results file using universal identifier to access the analytics results for the person. Additionally, the analytics results for the person may be provided to a user for intervention into the health of the person.

Abstract: A process for identifying functional and detailed design decisions in a core software architecture across multiple applications and clients includes comparing the results of two independent review sub processes to rapidly build an upgrade testing matrix. The two sub process include an independent functional review and a regression analysis using data extracts from historical data generated from client use of the core software architecture.

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: Systems and process for performing analytical processes on the health-related data for a person include components and steps for processing system multiple files from multiple sources containing health-related data for numerous individual. Such processing may include: staging health-related data; matching pieces of staged data to a person using one or more matching rules; compressing the matched staged data for the person into a compressed file through assignment of a universal identifier which is associated with the person; providing the compressed file to an analytics engine; and decompressing the at least one analytics results file using universal identifier to access the analytics results for the person. Additionally, the analytics results for the person may be provided to a user for intervention into the health of the person.

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: 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: 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: 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: 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 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: 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: 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 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 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: 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 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: 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: 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.