Abstract: A claim valuation engine is provided. The claim valuation engine enables a healthcare provider to accurately value an expected reimbursement of a claim from a payer based on a contract between the healthcare provider and the payer. Contract terms, code sets, fee schedules, and other valuation data is input into the engine. The engine receives a claim from a healthcare provider information system, locates a contract applicable for valuing the claim, correlates the claim attributes with the contract terms according to a hierarchy, and determines an expected reimbursement for each claim attribute or group of attributes. The claim valuation engine is further operable to determine contractual allowances, determine under and overpayments by validating remittances, and to simulate valuation of a contract by valuing a claim based on multiple sets of contract terms. The engine is further operable to generate output reports and post results to the healthcare provider information system.

Abstract: Validating patient payment estimates is provided. Validating patient payment estimates may comprise matching patient payment estimates with claims, payments and insurance contracts and providing tools to analyze the results of the matching process. Discrepancies may be determined, for example discrepancies between procedures and patient portions from the estimate with procedures actually billed and paid and a patient portion determined by the insurance company. Results may be stored in a dashboard user interface, which may then be available via a user interface for drill-down analysis.

Abstract: Automated criteria template generation and automated criteria population in a contract model for improving the efficiency, functionality, and accuracy of systems for contract modeling and claim valuation are provided. When modeling contracts for claim valuation, terms are entered into a contract model, and criteria are entered that determine whether a particular term matches an item on a claim. A contract modeling and claim valuation system collects and stores criteria data that have matched service terms during claim valuations, and prioritizes the criteria for building criteria templates for associated service terms. When a contract model is being built, and entry of a particular service term is received, the contract modeler searches for criteria templates that are associated with the service term. A criteria template is selected, and the criteria in the criteria template are automatically loaded into a criteria section of the contract modeler graphical user interface.

Abstract: A claim valuation engine is provided. The claim valuation engine enables a healthcare provider to accurately value an expected reimbursement of a claim from a payer based on a contract between the healthcare provider and the payer. Contract terms, code sets, fee schedules, and other valuation data is input into the engine. The engine receives a claim from a healthcare provider information system, locates a contract applicable for valuing the claim, correlates the claim attributes with the contract terms according to a hierarchy, and determines an expected reimbursement for each claim attribute or group of attributes. The claim valuation engine is further operable to determine contractual allowances, determine under and overpayments by validating remittances, and to simulate valuation of a contract by valuing a claim based on multiple sets of contract terms. The engine is further operable to generate output reports and post results to the healthcare provider information system.

Abstract: Validating patient payment estimates is provided. Validating patient payment estimates may comprise matching patient payment estimates with claims, payments and insurance contracts and providing tools to analyze the results of the matching process. Discrepancies may be determined, for example discrepancies between procedures and patient portions from the estimate with procedures actually billed and paid and a patient portion determined by the insurance company. Results may be stored in a dashboard user interface, which may then be available via a user interface for drill-down analysis.