Abstract: A computerized system and method for presenting payer-based health record (PBHR) data to a health care provider is disclosed. In an example embodiment, the member summary data is organized on one or more summary pages that contain recent, concise, and relevant information regarding a member of an insurance plan for use by a health provider as a quick reference when care is delivered. In the computerized system and method, a member summary data aggregation process is executed to extract from a member's health profile and claim data relevant information for a member summary. The information contained in a member summary is derived in relation to specific categories. The member summary provides an integrated report of clinically-relevant member-specific medical data for use by a health care provider when care is delivered to the member.

Abstract: Disclosed embodiments describe a system and method for identifying, evaluating and routing members of a healthcare benefits system to clinical interventions. The system includes various databases that comprise member claims data and provides the infrastructure to support the integration and exchange of data among representatives of a health benefits plan. It allows for more efficient use of information via the creation and evaluation of a clinical profile that is then used to identify the clinical interventions that may be appropriate for a member. The clinical data is matched to referral thresholds and other eligibility criteria for various clinical and disease management programs to identify appropriate interventions. Member progress in the interventions is tracked to determine whether additional interventions or actions may be needed to further engage the member in health-related activities. Members that do not respond to alerts for interventions may receive further alerts.