Abstract: A method including: receiving a plurality of data records from one or more sources; processing a plurality of steps for each data record of the plurality of data records; and adding one or more first data records of the plurality of data records to multiple different queues for manual processing based on one or more exception conditions being satisfied in two or more steps of the plurality of steps; routing each of the multiple different queues to different users having different roles for manual processing; and dynamically generating a different user interface for each of the different users based on the one or more first data records of the plurality of data records added to the multiple different queues for manual processing. Other embodiments are described.

Abstract: A method including: receiving one or more encounters to be submitted to one or more governmental entities for reimbursement after the encounters have been adjudicated and paid by a health insurance plan; verifying whether each of the one or more encounters comply with regulations specified by the one or more governmental entities to determine one or more improper encounters of the one or more encounters comprising one or more errors that do not comply with the regulations specified by the one or more governmental entities; correcting the one or more improper encounters of the one or more encounters to comply with the regulations specified by the one or more governmental entities; submitting the one or more encounters, including the one or more improper encounters, as corrected, to the one or more governmental entities for reimbursement; and receiving one or more responses from the one or more governmental entities corresponding to the one or more encounters. Other embodiments are provided.

Abstract: A method of adjudicating a medical claim includes providing a requirements for a first claim and a second claim, receiving a medical claim for a medical procedure, setting a first score for the first claim and a second score for the second claim to an initial value, comparing components of the medical claim to the requirements of the first and second claims, changing the first and second scores for each one of the components that match one of the requirements and for each one of the requirements that is missing from the components, and selecting the first or second claim based upon predetermined criteria applied to their respective scores to determine either a monetary value of the medical procedure for a medical service provider associated with the medical procedure or a monetary value of medical coverage for a patient associated with the medical procedure.

Abstract: A method including: receiving one or more encounters to be submitted to one or more governmental entities for reimbursement after the encounters have been adjudicated and paid by a health insurance plan; verifying whether each of the one or more encounters comply with regulations specified by the one or more governmental entities to determine one or more improper encounters of the one or more encounters comprising one or more errors that do not comply with the regulations specified by the one or more governmental entities; correcting the one or more improper encounters of the one or more encounters to comply with the regulations specified by the one or more governmental entities; submitting the one or more encounters, including the one or more improper encounters, as corrected, to the one or more governmental entities for reimbursement; and receiving one or more responses from the one or more governmental entities corresponding to the one or more encounters. Other embodiments are provided.

Abstract: A method including: receiving a plurality of data records from one or more sources, wherein each data record of the plurality of data records can include a data format, and each data record of the plurality of data records can include a transaction type; processing a plurality of steps for each data record of the plurality of data records, wherein the plurality of steps processed for each data record of the plurality of data records can differ depending on the transaction type of the data record, one or more of the plurality of steps can interface with each data record of the plurality of data records based on a data dictionary schema corresponding to the data format of the data record, and one or more first steps of the plurality of steps can be configured to conditionally add one or more first data records of the plurality of data records to one or more queues for manual processing; and adding the one or more first data records of the plurality of data records to the one or more queues for manual processing

Abstract: A method of adjudicating a medical claim includes providing a requirements for a first claim and a second claim, receiving a medical claim for a medical procedure, setting a first score for the first claim and a second score for the second claim to an initial value, comparing components of the medical claim to the requirements of the first and second claims, changing the first and second scores for each one of the components that match one of the requirements and for each one of the requirements that is missing from the components, and selecting the first or second claim based upon predetermined criteria applied to their respective scores to determine either a monetary value of the medical procedure for a medical service provider associated with the medical procedure or a monetary value of medical coverage for a patient associated with the medical procedure.

Abstract: A method of adjudicating a medical claim includes providing a requirements for a first claim and a second claim, receiving a medical claim for a medical procedure, setting a first score for the first claim and a second score for the second claim to an initial value, comparing components of the medical claim to the requirements of the first and second claims, changing the first and second scores for each one of the components that match one of the requirements and for each one of the requirements that is missing from the components, and selecting the first or second claim based upon predetermined criteria applied to their respective scores to determine either a monetary value of the medical procedure for a medical service provider associated with the medical procedure or a monetary value of medical coverage for a patient associated with the medical procedure.

Abstract: A method of adjudicating a medical claim includes providing a requirements for a first claim and a second claim, receiving a medical claim for a medical procedure, setting a first score for the first claim and a second score for the second claim to an initial value, comparing components of the medical claim to the requirements of the first and second claims, changing the first and second scores for each one of the components that match one of the requirements and for each one of the requirements that is missing from the components, and selecting the first or second claim based upon predetermined criteria applied to their respective scores to determine either a monetary value of the medical procedure for a medical service provider associated with the medical procedure or a monetary value of medical coverage for a patient associated with the medical procedure.

Abstract: A method of adjudicating a medical claim includes providing a requirements for a first claim and a second claim, receiving a medical claim for a medical procedure, setting a first score for the first claim and a second score for the second claim to an initial value, comparing components of the medical claim to the requirements of the first and second claims, changing the first and second scores for each one of the components that match one of the requirements and for each one of the requirements that is missing from the components, and selecting the first or second claim based upon predetermined criteria applied to their respective scores to determine either a monetary value of the medical procedure for a medical service provider associated with the medical procedure or a monetary value of medical coverage for a patient associated with the medical procedure.

Abstract: A method of adjudicating a medical claim includes providing a requirements for a first claim and a second claim, receiving a medical claim for a medical procedure, setting a first score for the first claim and a second score for the second claim to an initial value, comparing components of the medical claim to the requirements of the first and second claims, changing the first and second scores for each one of the components that match one of the requirements and for each one of the requirements that is missing from the components, and selecting the first or second claim based upon predetermined criteria applied to their respective scores to determine either a monetary value of the medical procedure for a medical service provider associated with the medical procedure or a monetary value of medical coverage for a patient associated with the medical procedure.

Abstract: A method of adjudicating a medical claim includes providing a requirements for a first claim and a second claim, receiving a medical claim for a medical procedure, setting a first score for the first claim and a second score for the second claim to an initial value, comparing components of the medical claim to the requirements of the first and second claims, changing the first and second scores for each one of the components that match one of the requirements and for each one of the requirements that is missing from the components, and selecting the first or second claim based upon predetermined criteria applied to their respective scores to determine either a monetary value of the medical procedure for a medical service provider associated with the medical procedure or a monetary value of medical coverage for a patient associated with the medical procedure.

Abstract: A method of adjudicating a medical claim includes providing a requirements for a first claim and a second claim, receiving a medical claim for a medical procedure, setting a first score for the first claim and a second score for the second claim to an initial value, comparing components of the medical claim to the requirements of the first and second claims, changing the first and second scores for each one of the components that match one of the requirements and for each one of the requirements that is missing from the components, and selecting the first or second claim based upon predetermined criteria applied to their respective scores to determine either a monetary value of the medical procedure for a medical service provider associated with the medical procedure or a monetary value of medical coverage for a patient associated with the medical procedure.