Abstract: An apparatus and method for processing health care transactions through a common interface in a distributed computing environment using specialized remote procedure calls. The distributed computing environment includes a user interface tier for collecting user inputs and presenting transaction outputs, a data access tier for data storage and retrieval of health care transaction information, a transaction logic tier for applying a predetermined set of transaction procedures to user inputs and health care transaction information resulting in transaction output, an electronic network connecting the user interface tier, data access tier and transaction logic tier to each other and a communication interface for exchanging health care transaction information among the tiers. The communication interface includes an interface definition language generating transaction-specific communication codes whereby data is exchanged through a common interface structure regardless of the origin of the data.

Abstract: A software-based medical information system performs a method of analyzing health care claims records for an enrolled population (e.g., HMO, Medicaid) to assess and report on quality of care based on conformance to nationally recognized medical practice guidelines or quality indicators.

Abstract: A computerized expert system reviews and adjudicates medical health care payment requests made by physicians to payers, such as insurers, for procedures performed and services and materials rendered to patients in the course of treatment. The system adjudicates a payment request to minimize fraud and mistakes and to determine whether to honor the request and if the request is honored, the dollar amount of the payment. The expert system reviews the payment request based on user-specified review criteria. Such criteria reflects contractual arrangements between payers, providers and patients, current, locally acceptable medical practices and patient and provider payment request patterns.