Use determination risk coverage datastructure for on-demand and increased efficiency coverage detection and rebalancing apparatuses, methods and systems
The Use Determination Risk Coverage Datastructure for On-Demand and Increased Efficiency Coverage Detection and Rebalancing Apparatuses, Methods and Systems (“UDRCD”) transforms coverage enrollment request, event signal inputs via UDRCD components into coverage enrollment response, add-in recommendation outputs. An event signal associated with a plan member enrolled into a plan that includes a core coverage component and an add-ins coverage component is obtained. Plan member data associated with the plan member is retrieved. A condition or procedure associated with the event signal is determined based on event signal data. An atomized add-in recommendation for the plan member is determined. The atomized add-in recommendation is provided to the plan member via an enrollment user interface. A selection of an atomized add-in is obtained from the plan member via the enrollment user interface. Addition of the selected atomized add-in to the add-ins coverage component of the plan is facilitated.
1 . A system comprising:
one or more processors; and
at least one memory storing processor-executable instructions that, when executed by any one or more of the one or more processors, cause the one or more processors to perform operations comprising:
receiving an event signal data structure indicating an event involving a healthcare plan member enrolled into a healthcare plan comprising (a) a healthcare core coverage component and (b) a related atomized add-in healthcare coverage component comprising healthcare coverage for a discrete provider, discrete medical service, or discrete medical condition that is distinct from the healthcare core coverage component;
receiving a healthcare plan member data structure comprising at least an identifier identifying the healthcare plan member;
predicting a probability that a medical condition or service will occur in association with the healthcare plan member based at least in part on processing the event signal data structure by one or more machine learning processes;
generating based at least in part on processing the probability and a set of healthcare add-ins available for addition to the healthcare plan by the healthcare plan member by the one or more machine learning processes, a healthcare add-in recommendation comprising a subset of healthcare add-ins, the subset of healthcare add-ins comprising a first healthcare add-in for the healthcare plan member;
providing, via a healthcare enrollment user interface, a plan option comprising the first healthcare add-in, wherein the plan option comprises a Personal Protection Plan (PPP) data structure comprising a coverage amount field and a pointer to one or more callable options for the healthcare add-in recommendation;
receiving, via the healthcare enrollment user interface, a selection of the plan option comprising the first healthcare add-in; and
storing, in a component collection storage, the selection of the plan option.
2 . The system of claim 1 , wherein the operations further comprise:
determining, an outstanding claim indicates the healthcare plan member and a first medical condition or service associated with the first healthcare add-in; and
facilitating processing the outstanding claim based at least in part on coverage provided by the first healthcare add-in.
3 . The system of claim 1 , wherein the event signal data structure comprises one or more of: a healthcare coverage search by the healthcare plan member, a healthcare electronic data interchange transaction involving the healthcare plan member, or an electronic health information message involving the healthcare plan member.
4 . The system of claim 1 , wherein the event signal data structure comprises a plurality of event signals, and wherein the medical condition or service is determined based at least in part on at least a subset of the plurality of event signals.
5 . The system of claim 1 , wherein the healthcare plan member data structure comprises one or more of: profile data of the healthcare plan member, clinical data of the healthcare plan member, or a plan structure of the healthcare plan.
6 . The system of claim 5 , wherein the medical condition or service is additionally determined based at least in part on the clinical data.
7 . The system of claim 5 , wherein generating the healthcare add-in recommendation is further based at least in part on the plan structure of the healthcare plan.
8 . The system of claim 5 , wherein generating the healthcare add-in recommendation is further based at least in part on the profile data.
9 . The system of claim 1 , wherein generating the healthcare add-in recommendation is further based at least in part on a first determination that the healthcare core coverage component does not provide coverage for the medical condition or service and a second determination that the related atomized add-in healthcare coverage component does not provide coverage for the medical condition or service.
10 . The system of claim 1 , wherein generating the healthcare add-in recommendation is further based at least in part on a third determination that a chronic condition add-in upgrade improves a prognosis the healthcare plan member.
11 . The system of claim 1 , wherein the healthcare add-in recommendation comprises two or more healthcare add-in options associated with two or more different services and a same medical condition.
12 . The system of claim 11 , wherein the two or more different services are determined based at least in part on care efficacy of the respective services.
13 . The system of claim 11 , wherein the two or more healthcare add-in options comprise available provider add-in options determined based at least in part on a proximity of a corresponding provider to a location associated with the healthcare plan member.
14 . The system of claim 1 , wherein adding the first healthcare add-in to the related atomized add-in healthcare coverage component of the healthcare plan results in one or more of an introduction of a copay amount or for a first service associated with the first healthcare add-in and an increased cost of the healthcare plan.
15 . The system of claim 1 , wherein the healthcare enrollment user interface comprises one or more of a toggle healthcare network selection switch, a co-pay slider selection mechanism, a health network informational widget, or a healthcare add-in upgrade toggle switch.
16 . One or more non-transitory computer-readable storage media storing processor-executable instructions that, when executed by one or more processors, cause the one or more processors to perform operations comprising:
receiving an event signal data structure indicating an event involving a healthcare plan member enrolled into a healthcare plan comprising (a) a healthcare core coverage component and (b) a related atomized add-in healthcare coverage component comprising healthcare coverage for a discrete provider, discrete medical service, or discrete medical condition that is distinct from the healthcare core coverage component;
receiving a healthcare plan member data structure comprising at least an identifier identifying the healthcare plan member;
predicting a probability that a medical condition or service will occur in association with the healthcare plan member based at least in part on processing the event signal data structure by one or more machine learning processes, a medical condition or service;
generating, based at least in part on processing the probability and a set of healthcare add-ins available for addition to the healthcare plan by the healthcare plan member by the one or more machine learning processes, a healthcare add-in recommendation comprising a subset of healthcare add-ins, the subset of healthcare add-ins comprising a first healthcare add-in for the healthcare plan member;
providing, via a healthcare enrollment user interface, a plan option comprising the first healthcare add-in, wherein the plan option comprises a Personal Protection Plan (PPP) data structure comprising a coverage amount field and a pointer to one or more callable options for the healthcare add-in recommendation;
receiving, via the healthcare enrollment user interface, a selection of the plan option comprising the first healthcare add-in; and
storing, in a component collection storage, the selection of the plan option.
17 . The one or more non-transitory computer-readable storage media of claim 16 , wherein (i) the healthcare plan member data structure comprises one or more of: profile data associated with the healthcare plan member, clinical data of the healthcare plan member, or a plan structure of the healthcare plan, (ii) the medical condition or service is additionally determined based at least in part on the clinical data, and (iii) generating the healthcare add-in recommendation is further based at least in part on at least one of the plan structure of the healthcare plan and the profile data.
18 . A system comprising:
means to store processor-executable instructions; and
means to process processor-executable instructions, wherein the processor-executable instructions are configured to cause the means to process processor-executable instructions to perform operations comprising:
receiving an event signal data structure indicating an event involving a healthcare plan member enrolled into a healthcare plan comprising (a) a healthcare core coverage component and (b) a related atomized add-in healthcare coverage component comprising healthcare coverage for a discrete provider, discrete medical service, or discrete medical condition that is distinct from the healthcare core coverage component;
receiving a healthcare plan member data structure comprising at least an identifier identifying the healthcare plan member;
predicting a probability that a medical condition or service will occur in association with the healthcare plan member based at least in part on processing the event signal data structure by one or more machine learning processes, a medical condition or service;
generating, based at least in part on processing the probability and a set of healthcare add-ins available for addition to the healthcare plan by the healthcare plan member by the one or more machine learning processes, a healthcare add-in recommendation comprising a subset of healthcare add-ins, the subset comprising a first healthcare add-in for the healthcare plan member;
providing, via a healthcare enrollment user interface, a plan option comprising the first healthcare add-in, wherein the plan option comprises a Personal Protection Plan (PPP) data structure comprising a coverage amount field and a pointer to one or more callable options for the healthcare add-in recommendation;
receiving, via the healthcare enrollment user interface, a selection of the plan option comprising the first healthcare add-in; and
storing, in a component collection storage, the selection of the plan option.
19 . A processor-executed method comprising:
receiving, by one or more processors, an event signal data structure indicating an event involving a healthcare plan member enrolled into a healthcare plan comprising (a) a healthcare core coverage component and (b) a related atomized add-in healthcare coverage component comprising healthcare coverage for a discrete provider, discrete medical service, or discrete medical condition that is distinct from the healthcare core coverage component;
receiving, by the one or more processors, a healthcare plan member data structure comprising at least an identifier identifying the healthcare plan member;
predicting, by the one or more processors, a probability that a medical condition or service will occur in association with the healthcare plan member based at least in part on processing the event signal data structure by one or more machine learning processes, a medical condition or service;
generating, by the one or more processors and based at least in part on processing the probability and a set of healthcare add-ins available for addition to the healthcare plan by the healthcare plan member by the one or more machine learning processes, a healthcare add-in recommendation comprising a subset of healthcare add-ins, the subset comprising a first healthcare add-in for the healthcare plan member;
providing, by the one or more processors and via a healthcare enrollment user interface, the healthcare add-in recommendation;
providing, via a healthcare enrollment user interface, a plan option comprising the first healthcare add-in, wherein the plan option comprises a Personal Protection Plan (PPP) data structure comprising a coverage amount field and a pointer to one or more callable options for the healthcare add-in recommendation;
receiving, via the healthcare enrollment user interface, a selection of the plan option comprising the first healthcare add-in; and
storing, by the one or more processors and in a component collection storage, the selection of the plan option.
20 . The processor-executed method of claim 19 , wherein (i) the healthcare plan member data structure comprises one or more of: profile data associated with the healthcare plan member, clinical data of the healthcare plan member, or a plan structure of the healthcare plan, (ii) the medical condition or service is additionally determined based at least in part on the clinical data, and (iii) generating the healthcare add-in recommendation is further based at least in part on at least one of the plan structure of the healthcare plan and the profile data.