Abstract: Methods and systems for interactively creating and submitting insurance claims and determining whether the submitted claims are in condition for payment by an insurer. A medical technician operating a client computer establishes communication with a remote server. The remote server transmits a claim form to the client computer for display to the medical technician. Using the claim form, the technician enters patient identification information, which is transmitted to the server to determine whether the patient is a beneficiary of an approved insurance plan. If the patient is a beneficiary, the technician can prepare an insurance claim using the claim form displayed by the client computer. The technician enters a diagnosis code and a treatment code representing the diagnosis and treatment of the patient. The diagnosis and treatment codes are transmitted to the remote server, which processes the codes to determine whether the claim corresponds to health care services that are approved for payment.

Abstract: A claims processing system for electronically reviewing and adjudicating medical insurance claims. The claims processing systems include a benefits system, an automated adjudication system, a payment system, and a payment tracking system. The benefits system allows patients and health care providers to access patient and benefits information on-line. Using the automated adjudication system, health care providers may electronically prepare and submit claims for payment. Before a claim is submitted, a claims precheck process is used to determine whether the claim may be automatically adjudicated or instead must be manually adjudicated. If manual adjudication is indicated, the health care provider may the claim in an effort to achieve automated adjudication prior to claim submission. The claims processing system performs automatic adjudication on submitted claims or forwards the claims to a shop for manual adjudication.

Abstract: Methods and systems for interactively creating and submitting insurance claims and determining whether the submitted claims are in condition for payment by an insurer. A medical technician operating a client computer establishes communication with a remote server. The remote server transmits a claim form to the client computer for display to the medical technician. Using the claim form, the technician enters patient identification information, which is transmitted to the server to determine whether the patient is a beneficiary of an approved insurance plan. If the patient is a beneficiary, the technician can prepare an insurance claim using the claim form displayed by the client computer. The technician enters a diagnosis code and a treatment code representing the diagnosis and treatment of the patient. The diagnosis and treatment codes are transmitted to the remote server, which processes the codes to determine whether the claim corresponds to health care services that are approved for payment.