Abstract: A system and method for implementing an insurance plan to coordinate an adjudication of a submitted claim corresponding to the plan. The plan includes a people model and a benefit model, such as hierarchical trees combined by a plurality of policies. The system and method comprise assigning a first predefined inheritance of global attributes to coupled elements of the people tree and assigning a second predefined inheritance of global attributes to coupled elements of the benefits tree. The system and method also assigning a local administration rule for at least one local attribute of the trees, the assignment between a selected people element of the people tree and a selected benefit element of the benefits tree. The local administration rule overrides the corresponding global attributes of the selected elements, such that resolution of the global attributes with the local attributes for the selected elements provides a rule set for adjudication of the submitted claim.

Abstract: A system and method for implementing an insurance plan to coordinate an adjudication of a submitted claim corresponding to the plan. The plan includes a people model and a benefit model, such as hierarchical trees combined by a plurality of policies. The system and method comprise assigning a first predefined inheritance of global attributes to coupled elements of the people tree and assigning a second predefined inheritance of global attributes to coupled elements of the benefits tree. The system and method also assigning a local administration rule for at least one local attribute of the trees, the assignment between a selected people element of the people tree and a selected benefit element of the benefits tree. The local administration rule overrides the corresponding global attributes of the selected elements, such that resolution of the global attributes with the local attributes for the selected elements provides a rule set for adjudication of the submitted claim.

Abstract: A real time claim processing system, the system comprising: an electronic claim submission interface; an eligibility processor of claim data supplied through the claim interface; a repricing processor for repricing the claim data; an adjudication processor for adjudicating the repriced claim data to provide adjudication details; and a payment processor for providing payment details of the adjudicated claim; wherein a real time response is provided to a provider of the claim data supplying adjudication and payment details.