Health care patient benefits eligibility research system and methods
View Patent ↗The software of the present invention provides a means for creating a file of unpaid claims for a service provider. The software is used to create one or more queries to compare information in the file of claims against records in a benefit provider's database to determine the eligibility status of the claim. A file is created containing each claim for which a matching record in the benefit provider's database is found, and the information from that matching record. A report can be generated from the file of matching claims and benefit provider records, so the claims can be submitted for payment by the service provider.
1. A tangible computer program product for determining eligibility of medical care claims having a computer readable medium with a computer program executable by a computer embodied thereon, the computer program comprising:
a) computer code for finding a record in a benefit provider's database that corresponds at least in part to two or more fields of information on a claim associated with a patient in a service provider's database, wherein an error exists in the data associated with said patient in the benefit provider's database, the service provider's database, or both the benefit provider's database and the service provider's database;
b) computer code for comparing one or more fields of said record to one or more fields of said claim to validate whether said record is associated with said patient; and
c) computer code for placing said claim and said record in a file.
2. The computer program product of claim 1 further comprising computer code for submitting said claim to the benefit provider for payment.
3. A computerized data processing system for analyzing medical care claims to determine claim eligibility status, said system comprising computer readable instructions and a processor for executing said instructions, said instructions comprising computer code for:
a) creating a file of a service provider's claims in a machine-readable format;
b) preparing one or more queries to find records in at least one benefit provider's database that match, at least in part, one or more claims in the file of the service provider's claims;
c) executing a first query for the first claim in the file of claims;
d) when the query finds a matching record in the at least one benefit provider's database that matches the claim (such claim being referred to hereafter as a matched claim), obtaining the information contained in the matching record;
e) associating the information from the matching record with the matched claim;
f) inserting the matched claim and the information from the matching record from the at least one benefit provider's database in a second file;
g) removing the matched claim from the file of the service provider's claims;
h) repeating steps c through g for each subsequent claim in the file of the service provider's claims;
i) determining if there are any additional queries to be performed and, if so, for each additional query, executing steps c through h; and
j) creating a report of the information in the second file.
4. The system of claim 3 wherein said instructions further comprise computer code for querying the second file of matched claims and associated information from the at least one benefit provider's database to determine if the date a service was provided for a patient is within a time period for which the patient was covered by the at least one benefit provider.
5. The system of claim 3 wherein said instructions further comprise computer code for submitting the information from the report to the at least one benefit provider for payment of the claims contained therein.
6. The system of claim 3 wherein said instructions further comprise computer code for using the report to create at least one claim form for submission to the at least one benefit provider for payment.
7. The system of claim 3 wherein said instructions further comprise computer code for determining if the matching record for a claim is for a same person as the service provider's claim.
8. A method employed with a data processing system for determining eligibility of unpaid medical claims, the method comprising:
a) creating a file of claims for a health care service provider, the file containing at least one field for each claim;
b) accessing a database of patient records for a benefit provider;
c) comparing at least a portion of at least one field for at least one claim in the file of claims to at least a portion of at least one associated field in at least one patient record in the database of patient records for the benefit provider;
d) if the compared fields match at least in part, placing the at least one claim (said at least one claim being referred to hereafter as a matched claim) and the information from the at least one associated field of the at least one patient record (said at least one patient record being referred to hereafter as a matching patient record) in a file of matching records; and
e) removing the matched claim from the file of claims.
9. The method of claim 8 further comprising comparing at least one portion of at least one field of at least a second claim to at least one portion of at least one second associated field in at least one patient record in the database of patient records for the benefit provider, and if said at least one field of said at least a second claim matches said at least one second associated field at least in part, placing the at least a second claim and the information from the at least one second associated field in the file of matching records, and removing said second claim from the file of claims.
10. The method of claim 8 further comprising generating a report from the file of matching records including claim information and information from the matching patient record.
11. A tangible computer program product for determining eligibility of medical care claims having a computer readable medium with a computer program embodied thereon, the computer program comprising instructions executable by a computer processor for:
a) defining a query representative of a first field and a second field of information in a claim in a service provider's database, said claim comprising information regarding a patient and a medical service provided to said patient;
b) executing said query on a benefit provider's database to identify a record in the benefit provider's database wherein said first and second fields are switched;
c) comparing one or more fields of said record to one or more fields of said claim to validate whether said record is associated with said patient; and
d) if said record is associated with said patient, placing said claim and said record into a file.
12. A tangible computer program product for determining eligibility of medical care claims having a computer readable medium with a computer program embodied thereon, the computer program comprising instructions executable by a computer processor for:
a) defining a query representative of a field of information in a claim in a service provider's database, said claim comprising information regarding a patient and a medical service provided to said patient;
b) executing said query on a benefit provider's database to identify a record in the benefit provider's database comprising an alternate representation of said field;
c) comparing one or more fields of said record to one or more fields of said claim to validate whether said record is associated with said patient; and
d) if said record is associated with said patient, placing said claim and said record into a file.