System and method for enhancing and authenticating an insurance eligibility transaction
View Patent ↗The disclosure presents a system, method, and computer readable medium for execution on a computer processor, for authenticating and enhancing an insurance eligibility transaction, such as a 270/271 healthcare system transaction. In a particular embodiment, an insurance eligibility transaction request, such as a 270 transaction, is received/intercepted by the system prior to being received by the payor and data from one or more sources, such as a credit bureau database containing credit file data, is used to enhance, verify and correct the accuracy of data fields particular to the insurance eligibility transaction. The payor's database(s) can also be enhanced accordingly. The system also has capability to, among other things, identify fraud-related issues, charity qualification, and patient payment estimation as part of the transaction.
1. A non-transitory computer readable medium comprising program code that when executed by a computer processor within a system, conducts the operations of authenticating and enhancing an insurance eligibility transaction, the code comprising:
a first code segment executed by the computer processor, conducting the operation of receiving at the system an insurance eligibility transaction request having target personal information of a person associated with the insurance eligibility transaction request;
a second code segment executed by the computer processor, conducting the operation of querying demographic data within a personal identity database, wherein the data is not derived from an insurance eligibility transaction;
a third code segment executed by the computer processor, conducting the operation of, determining whether the target personal information matches the demographic data within the personal identity database; and
a fourth code segment executed by the computer processor, conducting the operation of, transmitting from the system the insurance eligibility transaction request having the verified personal information therein to a payor to facilitate determination of whether the insurance eligibility request should be granted and to facilitate determination of eligibility terms under which the insurance eligibility request should be granted.
2. The non-transitory computer readable medium of claim 1 , the code further comprising:
a fifth code segment executed by the computer processor, conducting the operation of designating the target personal information as verified personal information, when there is a match between the target personal information and the demographic data, wherein the insurance eligibility transaction request comprises the verified personal information.
3. The non-transitory computer readable medium of claim 1 , the code further comprising:
a fifth code segment executed by the computer processor appending associated demographic information from within the personal identity database to the target personal information within the insurance eligibility transaction request.
4. The non-transitory computer readable medium of claim 1 wherein the associated demographic information comprises demographic information that was not previously comprised within insurance eligibility transaction request.
5. The non-transitory computer readable medium of claim 1 wherein the associated demographic information comprises at least one of a name, an address, a social security number, insurance member identification code, insurance group code, insurance card issue date, date of birth, and/or credit score.
6. The non-transitory computer readable medium of claim 1 wherein the associated demographic information comprises alert information.
7. The non-transitory computer readable medium of claim 6 wherein the alert information comprises an indication of fraud.
8. The non-transitory computer readable medium of claim 1 wherein the target personal information is at least one of a target name, an target address, a target social security number, a target insurance member identification code, a target insurance group code, a target insurance card issue date, a target date of birth.
9. The non-transitory computer readable medium of claim 1 wherein the person is at least one of a policy holder insured and/or a patient.
10. The non-transitory computer readable medium of claim 1 wherein the personal identity database is a personal credit reporting database.
11. The non-transitory computer readable medium of claim 1 wherein the personal identity database is a subset of a personal credit reporting database.
12. The non-transitory computer readable medium of claim 1 wherein the insurance eligibility transaction request is received from a healthcare provider.
13. The non-transitory computer readable medium of claim 1 , the code further comprising:
a fifth code segment executed by the computer processor receiving at the system an insurance eligibility transaction response having a coverage determination of whether the insurance eligibility request should be granted for the person and having eligibility terms for the person when a positive coverage determination is provided; and,
a sixth code segment executed by the computer processor appending additional associated demographic information from within the personal identity database to the insurance eligibility transaction response.
14. The non-transitory computer readable medium of claim 1 , the code further comprising:
a fifth code segment executed by the computer processor receiving at the system an insurance eligibility transaction response having a coverage determination of whether the insurance eligibility request should be granted for the person and having eligibility terms for the person when a positive coverage determination is provided, wherein the eligibility terms comprises benefit levels including at least one of co-pay information and/or deductible information.
15. The non-transitory computer readable medium of claim 1 , the code further comprising:
a fifth code segment executed by the computer processor receiving at the system an insurance eligibility transaction response having a coverage determination of whether the insurance eligibility request should be granted for the person and having eligibility terms for the person when a positive coverage determination is provided;
a sixth code segment executed by the computer processor, querying ancillary data within an ancillary data database;
a seventh code segment executed by the computer processor, determining whether the demographic data and/or the target personal information may have been used in a fraudulent manner; and,
an eighth code segment executed by the computer processor transmitting from the system the insurance eligibility transaction response having the coverage determination therein to a healthcare provider.
16. The non-transitory computer readable medium of claim 1 , the code further comprising:
a fifth code segment executed by the computer processor receiving at the system an insurance eligibility transaction response having a coverage determination of whether the insurance eligibility request should be granted for the person;
a sixth code segment executed by the computer processor determining, whether the person qualifies for third party subsidy payments when the coverage determination is less than a maximum threshold level; and, a seventh code segment executed by the computer processor appending third party subsidy payment information to the insurance eligibility transaction response if the person qualifies for third party subsidy payments.
17. The non-transitory computer readable medium of claim 16 wherein the maximum threshold level is greater than zero coverage.
18. The non-transitory computer readable medium of claim 1 , the code further comprising:
a fifth code segment executed by the computer processor receiving at the system an insurance eligibility transaction response having coverage determination information comprising a determination of whether the insurance eligibility request should be granted for the person;
a sixth code segment executed by the computer processor estimating an amount of coverage based on coverage determination information provided within the insurance eligibility transaction response; and,
a seventh code segment executed by the computer processor appending the coverage estimation to the insurance eligibility transaction response.
19. The non-transitory computer readable medium of claim 18 wherein the response is an ANSI X12 271 healthcare system transaction.
20. The non-transitory computer readable medium of claim 1 wherein the request is an ANSI X12 270 healthcare system transaction.
21. A non-transitory computer readable medium comprising program code for execution on a computer processor within a system, for authenticating and enhancing an insurance eligibility transaction, the code comprising:
a first code segment executed by the computer processor receiving at the system an insurance eligibility transaction response having a coverage determination of whether an insurance eligibility request should be granted for a person and having eligibility terms for the person if a positive coverage determination is provided; and,
a second code segment executed by the computer processor appending additional associated demographic information from within a personal identity database to the insurance eligibility transaction response, wherein the demographic information is not derived from an insurance eligibility transaction.
22. A non-transitory computer readable medium comprising program code for execution on a computer processor within a system, for authenticating and enhancing an insurance eligibility transaction, the code comprising:
a first code segment executed by the computer processor receiving at the system an insurance eligibility transaction response having a coverage determination of whether an insurance eligibility request should be granted for a person and having eligibility terms for the person when a positive coverage determination is provided;
a second code segment executed by the computer processor querying ancillary data not associated with an insurance eligibility transaction within an ancillary data database;
a third code segment executed by the computer processor determining, using the processor, whether demographic data and/or target personal information may have been used in a fraudulent manner and generating an alert if there is a positive determination; and,
a fourth code segment executed by the computer processor transmitting from the system the insurance eligibility transaction response having the coverage determination and the alert therein to a healthcare provider.
23. A non-transitory computer readable medium comprising program code for execution on a computer processor within a system, for authenticating and enhancing an insurance eligibility transaction, the code comprising:
a first code segment executed by the computer processor receiving at the system an insurance eligibility transaction response having a coverage determination of whether an insurance eligibility request should be granted for a person;
a second code segment executed by the computer processor determining, using the processor, whether the person qualifies for third party subsidy payments if the coverage determination is less than a maximum threshold level; and,
a fourth code segment executed by the processor appending third party subsidy payment information to the insurance eligibility transaction response if the person qualifies for third party subsidy payments.
24. A non-transitory computer readable medium comprising program code for execution on a computer processor within a system, for authenticating and enhancing an insurance eligibility transaction, the code comprising:
a first code segment executed by the computer processor receiving at the system an insurance eligibility transaction response having coverage determination information comprising a determination of whether the insurance eligibility request should be granted for a person;
a second code segment executed by the computer processor estimating an amount of coverage based on coverage determination information provided within the insurance eligibility transaction response; and,
a third code segment executed by the computer processor appending the coverage estimation to the insurance eligibility transaction response.
25. A system for authenticating and enhancing an insurance eligibility transaction, comprising:
an authentication and enhancement computer having a processor and an associated memory, the memory having authentication and enhancement program code, wherein the program code is configured to receive at the system an insurance eligibility transaction request having target personal information for a person associated with the insurance eligibility transaction request;
a demographic database within a personal identity database, wherein the demographic database is not derived from insurance eligibility transactions, the program code being further configured to query the demographic data using the processor, and to determine whether the target personal information matches the demographic data within the personal identity database, using the processor; and wherein the program code is further configured to transmit from the system the insurance eligibility transaction request having the verified personal information therein to a payor to facilitate determination of whether the insurance eligibility request should be granted and to facilitate determination of eligibility terms under which the insurance eligibility request should be granted.
26. The system of claim 25 wherein the program code is further configured to append, using the processor, associated demographic information from within the personal identity database to the target personal information within the insurance eligibility transaction request.
27. A system for authenticating and enhancing an insurance eligibility transaction, comprising:
an authentication and enhancement computer having a processor and an associated memory, the memory having authentication and enhancement program code, wherein the program code is configured to receive at the system an insurance eligibility transaction response having a coverage determination of whether the insurance eligibility request should be granted for the person and having eligibility terms for the person when a positive coverage determination is provided, wherein the eligibility terms comprises benefit levels including at least one of co-pay information and/or deductible information; and, a demographic database within a personal identity database, wherein the demographic database is not derived from insurance eligibility transactions, the program code being further configured to query, using the processor, the demographic data, and to append, using the processor, additional associated demographic information from within the personal identity database to the insurance eligibility transaction response.
28. A method performed by an insurance eligibility transaction authentication and enhancement computer, for authenticating and enhancing an insurance eligibility transaction, comprising the steps of:
receiving at the computer an electronic insurance eligibility transaction request having target personal information for a person associated with the insurance eligibility transaction request;
querying, using the processor, non-insurance eligibility derived demographic data within a personal identity database stored within computer memory;
determining, using the processor, whether the target personal information matches the demographic data within the personal identity database; and,
transmitting from the computer the insurance eligibility transaction request having the verified personal information therein to a payor to facilitate determination of whether the insurance eligibility request should be granted and to facilitate determination of eligibility terms under which the insurance eligibility request should be granted.
29. The method of claim 28 further comprising the step of:
designating, using the processor, the target personal information as verified personal information, when there is a match between the target personal information and the demographic data, wherein the insurance eligibility transaction request comprises the verified personal information.
30. The method of claim 28 further comprising the step of:
appending, using the processor, associated demographic information from within the personal identity database to the target personal information within the insurance eligibility transaction request.