System and method for validating medical claim data

1. A computerized method for validating medical claim data, the computerized method comprising:

receiving a first and second medical claim, each respectively associated with a first and a second healthcare classification system;

receiving claim edit criteria comprising providing a user interface for receiving configuration data including the claim edit criteria, wherein the claim edit criteria comprises one of a benefit or clinical rule configured to validate one of the medical claims, wherein each of the benefit or clinical rule comprises a healthcare payer policy requirement;

storing the first and second medical claims in association with the first and the second classification systems, respectively, said storing comprising testing a connection associated with a selected set of database server settings upon receiving a user test connection input;

validating the stored medical claims by applying each of the benefit rule and the clinical rule of the received claim edit criteria independently to each of the stored first and second medical claims and to the associated classification system so that each of the benefit rule and the clinical rule are validated independently for each of said first and second healthcare classification systems, wherein the validating step further comprises:

determining if the at least one of the stored medical claims meets the healthcare payer policy requirement of the benefit or clinical rule; and

rejecting the at least one of the stored medical claims if the at least one of the stored medical claims does not meet the healthcare payer policy requirement of the benefit or clinical rule; and

graphically displaying selected results of the validating,

wherein said clinical rule comprises stored medical procedure qualification information associated with a medical service provider indicative of whether or not said medical service provider has a medical specialty that matches a clinical eligibility criterion for a procedure code identified in each of said first and second store medical claims.

2. The computerized method of claim 1 , further comprising, upon validating of the stored medical claim, accepting the stored medical claim as a processed claim.

3. The computerized method of claim 1 , wherein the claim edit criteria include a maximum and minimum age healthcare payer policy requirement corresponding to a service provided to the member.

4. The computerized method of claim 1 , wherein the claim edit criteria include an availability of a service provided to the member healthcare payer policy requirement, wherein the member is an out-of-network member.

5. The computerized method of claim 1 , wherein the claim edit criteria include a valid procedure code corresponding to a diagnosis code healthcare payer policy requirement.

6. The computerized method of claim 1 , wherein the user interface for receiving configuration data comprises a mechanism configured to allow the user to upload the configuration data including the claim edit criteria comprising the one of the benefit, or clinical rule configured to validate one of the medical claims and further comprising the benefit or clinical rule healthcare payer policy requirement.

7. The computerized method of claim 1 , wherein the claim edit criteria further comprises a financial rule comprising a healthcare payer policy requirement.

8. The computerized method of claim 7 , further wherein the validating step further comprises:

determining if the at least one of the stored medical claims meets the healthcare payer policy requirement of the financial rule; and

rejecting the at least one of the stored medical claims if the at least one of the stored medical claims does not meet the healthcare payer policy requirement of the financial rule.

9. A system for validating medical claim data of a member, the computerized system comprising:

one or more computing devices including a memory having program code stored therein and a processor in communication with the memory for carrying out instructions in accordance with the stored program code, wherein the program code, when executed by the processor, causes the processor to:

receive a first and second medical claim, each respectively associated with a first and a second healthcare classification system;

receive claim edit criteria comprising providing a user interface for receiving configuration data including the claim edit criteria, wherein the claim edit criteria comprises one of a benefit or clinical rule configured to validate one of the medical claims, wherein each of the benefit or clinical rule comprises a healthcare payer policy requirement;

store the first and second medical claims in association with the first and the second classification systems, respectively, said storing comprising testing a connection associated with a selected set of database server settings upon receiving a user test connection input;

validate the stored medical claims by applying each of the benefit rule and the clinical rule of the received claim edit criteria independently to each of the stored first and second medical claims and to the associated classification system so that each of the benefit rule and the clinical rule are validated independently for each of said first and second healthcare classification systems, the program code further causes the processor to:

determine if the at least one of the stored medical claims meets the healthcare payer policy requirement of the benefit or clinical rule; and

reject the at least one of the stored medical claims if the at least one of the stored medical claims does not meet the healthcare payer policy requirement of the benefit or clinical rule; and

graphically display selected results of the validating,

wherein said clinical rule comprises stored medical procedure qualification information associated with a medical service provider indicative of whether or not said medical service provider has a medical specialty that matches a clinical eligibility criterion for a procedure code identified in each of said first and second stored medical claims.

10. The system of claim 9 , wherein the program code, when executed by the processor, further causes the processor to accept the stored medical claim as a processed claim upon the stored medical claim meeting the claim edit criteria validation.

11. The system of claim 9 , wherein the claim edit criteria include a maximum and minimum age healthcare payer policy requirement corresponding to a service provided to the member.

12. The system of claim 9 , wherein the claim edit criteria include an availability of a service provided to the member healthcare payer policy requirement, wherein the member is an out-of-network member.

13. The system of claim 9 , wherein the claim edit criteria include a valid procedure code corresponding to a diagnosis code healthcare payer policy requirement.

14. The computerized system of claim 9 , wherein the claim edit criteria further comprises a financial rule comprising a healthcare payer policy requirement.

15. The computerized method of claim 14 , wherein to complete the validation, the program code further causes the processor to:

determine if the at least one of the stored medical claims meets the healthcare payer policy requirement of the financial rule; and

reject the at least one of the stored medical claims if the at least one of the stored medical claims does not meet the healthcare payer policy requirement of the financial rule.

16. A non-transitory computer readable medium upon which is embodied a sequence of programmed instructions which, when executed by a processor, cause the processor to perform steps comprising:

receiving a first and second medical claim, each respectively associated with a first and a second healthcare classification system;

receiving claim edit criteria comprising providing a user interface for receiving configuration data including the claim edit criteria, wherein the claim edit criteria comprises one of a benefit or clinical rule configured to validate one of the medical claims, wherein each of the benefit or clinical rule comprises a healthcare payer policy requirement;

storing the first and second medical claims in association with the first and the second classification systems, respectively, said storing comprising testing a connection associated with a selected set of database server settings upon receiving a user test connection input;

validating the stored medical claims by applying each of the benefit rule and the clinical rule of the received claim edit criteria independently to each of the stored first and second medical claims and to the associated classification system so that each of the benefit rule and the clinical rule are validated independently for each of said first and second healthcare classification systems, wherein the code for validating further comprises:

determining if the at least one of the stored medical claims meets the healthcare payer policy requirement of the benefit or clinical rule; and

rejecting the at least one of the stored medical claims if the at least one of the stored medical claims does not meet the healthcare payer policy requirement of the benefit or clinical rule; and

graphically displaying selected results of the validating,

wherein said clinical rule comprises stored medical procedure qualification information associated with a medical service provider indicative of whether or not said medical service provider has a medical specialty that matches a clinical eligibility criterion for a procedure code identified in each of said first and second stored medical claims.

17. The non-transitory computer readable medium of claim 16 , further comprising accepting the stored medical claim as a processed claim upon the stored medical claim meeting the claim edit criteria validation.

18. The computer program product of claim 16 , wherein the claim edit criteria include a maximum and minimum age healthcare payer policy requirement corresponding to a service provided to the member.

19. The computer program product of claim 16 , wherein the claim edit criteria include an availability of a service provided to the member healthcare payer policy requirement, wherein the member is an out-of-network member.

20. The computer program product of claim 16 , wherein the claim edit criteria further comprises a financial rule comprising a healthcare payer policy requirement.

21. The non-transitory computer readable medium of claim 20 , wherein the validating further comprises:

determining if the at least one of the stored medical claims meets the healthcare payer policy requirement of the financial rule; and

rejecting the at least one of the stored medical claims if the at least one of the stored medical claims does not meet the healthcare payer policy requirement of the financial rule.