Processing of transaction records in a database based on reason codes
Embodiments of the present disclosure are directed to methods and systems for the timely processing of records exchanged between service provider systems and responsible entity systems by a records management and processing system. More specifically, the records management and processing system can maintain a set of rules defining conditions for processing records and associated actions to affect that processing upon satisfaction of or failure to satisfy the conditions of that rule. Updates to some or all of these records can be received from a data update service. The records management and processing system can apply the rules to the records and assign tags to the records based on the received update information and the conditions defined in the applied rules. The records management and processing system can then process the updated records according to workflows for processing the updated records based on the assigned tags and applied rules.
1. A method for processing transaction records in a database, the method comprising:
maintaining, by a records management and processing system, a plurality of records in a database, each record of the plurality of records comprising a record of a health care service provided to a consumer by a health care service provider of a plurality of health care service providers and identifying at least one required action by at least one responsible entity of a plurality of responsible entities, wherein each responsible entity comprises a third-party payor for health care services and wherein the records management and processing system comprises an intermediary between systems of the plurality of service providers and systems of the plurality of responsible entities;
receiving, by the records management and processing system, a set of update information related to at least one record of the plurality of records, wherein the update information comprises information indicating a current status of processing of the at least one record by one or more of the systems of the plurality of service providers and information indicating a reason for the current status by the one or more of the systems of the plurality of service providers;
determining, by the records management and processing system, to process the at least one record of the plurality of records based on the information indicating the current status of processing of the at least one record from the set of update information;
reading, by the records management and processing system, the information indicating the reason for the current status of the at least one record from the received update information;
normalizing, by the records management and processing system, the information indicating the reason for the current status from the update information; and
processing, by the records management and processing system, the at least one record based on the normalized information indicating the reason for the current status and according to one or more workflows executed by the records management and processing system, wherein the one or more workflows process the at least one record based on the received update information and actions defined in one or more predefined rules.
2. The method of claim 1 , further comprising, prior to normalizing the information indicating the reason for the current status from the update information, verifying the information indicating the current status of processing of the at least one record and wherein normalizing the information indicating the reason for the current status and processing the at least one record are performed in response to determining the information indicating the current status of processing is valid.
3. The method of claim 2 , further comprising, in response to determining the information indicating the current status of processing is not valid, processing the at least one record according to a workflow executed by the records management and processing system.
4. The method of claim 3 , wherein processing the at least one record according to the workflow comprises initiating an appeal process.
5. The method of claim 1 , wherein normalizing the information indicating the reason for the current status and processing the at least one record based on the normalized information indicating the reason for the current status and according to one or more workflows comprises applying a decision tree, wherein the decision tree comprises one or more branch nodes, each branch node representing a decision, and a plurality of leaf nodes, each leaf node representing a workflow.
6. The method of claim 5 , wherein the decision tree comprises at least one branch node representing a decision based on the information indicating the reason for the current status.
7. The method of claim 5 , wherein the decision tree comprises at least one branch node representing a decision based on information from the at least one record.
8. A system comprising:
a processor; and
a memory coupled with and readable by the processor and storing therein a set of instructions which, when executed by the processor, causes the processor to process a denied transaction record in a database by:
maintaining a plurality of records in a database, each record of the plurality of records comprising a record of a health care service provided to a consumer by a health care service provider of a plurality of health care service providers and identifying at least one required action by at least one responsible entity of a plurality of responsible entities, wherein each responsible entity comprises a third-party payor for health care services and wherein the records management and processing system comprises an intermediary between systems of the plurality of service providers and systems of the plurality of responsible entities;
receiving a set of update information related to at least one record of the plurality of records, wherein the update information comprises information indicating a current status of processing of the at least one record by one or more of the systems of the plurality of service providers and information indicating a reason for the current status by the one or more of the systems of the plurality of service providers;
determining to process the at least one record of the plurality of records based on the information indicating the current status of processing of the at least one record from the set of update information;
reading the information indicating the reason for the current status of the at least one record from the received update information;
normalizing the information indicating the reason for the current status from the update information; and
processing the at least one record based on the normalized information indicating the reason for the current status and according to one or more workflows executed by the records management and processing system, wherein the one or more workflows process the at least one record based on the received update information and actions defined in one or more predefined rules.
9. The system of claim 8 , further comprising, prior to normalizing the information indicating the reason for the current status from the update information, verifying the information indicating the current status of processing of the at least one record and wherein normalizing the information indicating the reason for the current status and processing the at least one record are performed in response to determining the information indicating the current status of processing is valid.
10. The system of claim 9 , further comprising, in response to determining the information indicating the current status of processing is not valid, processing the at least one record according to a workflow executed by the records management and processing system.
11. The system of claim 10 , wherein processing the at least one record according to the workflow comprises initiating an appeal process.
12. The system of claim 8 , wherein normalizing the information indicating the reason for the current status and processing the at least one record based on the normalized information indicating the reason for the current status and according to one or more workflows comprises applying a decision tree, wherein the decision tree comprises one or more branch nodes, each branch node representing a decision, and a plurality of leaf nodes, each leaf node representing a workflow.
13. The system of claim 12 , wherein the decision tree comprises at least one branch node representing a decision based on the information indicating the reason for the current status.
14. The system of claim 13 , wherein the decision tree further comprises at least one branch node representing a decision based on information from the at least one record.
15. A non-transitory, computer-readable medium comprising a set of instructions stored therein which, when executed by a processor, causes the processor to process a denied transaction record in a database by:
maintaining, by a records management and processing system, a plurality of records in a database, each record of the plurality of records comprising a record of a health care service provided to a consumer by a health care service provider of a plurality of health care service providers and identifying at least one required action by at least one responsible entity of a plurality of responsible entities, wherein each responsible entity comprises a third-party payor for health care services and wherein the records management and processing system comprises an intermediary between systems of the plurality of service providers and systems of the plurality of responsible entities;
receiving, by the records management and processing system, a set of update information related to at least one record of the plurality of records, wherein the update information comprises information indicating a current status of processing of the at least one record by one or more of the systems of the plurality of service providers and information indicating a reason for the current status by the one or more of the systems of the plurality of service providers;
determining, by the records management and processing system, to process the at least one record of the plurality of records based on the information indicating the current status of processing of the at least one record from the set of update information;
reading, by the records management and processing system, the information indicating the reason for the current status of the at least one record from the received update information;
normalizing, by the records management and processing system, the information indicating the reason for the current status from the update information; and
processing, by the records management and processing system, the at least one record based on the normalized information indicating the reason for the current status and according to one or more workflows executed by the records management and processing system, wherein the one or more workflows process the at least one record based on the received update information and actions defined in one or more predefined rules.
16. The non-transitory, computer-readable medium of claim 15 , further comprising, prior to normalizing the information indicating the reason for the current status from the update information, verifying the information indicating the current status of processing of the at least one record and wherein normalizing the information indicating the reason for the current status and processing the at least one record are performed in response to determining the information indicating the current status of processing is valid.
17. The non-transitory, computer-readable medium of claim 16 , further comprising, in response to determining the information indicating the current status of processing is not valid, processing the at least one record according to a workflow executed by the records management and processing system.
18. The non-transitory, computer-readable medium of claim 17 , wherein processing the at least one record according to the workflow comprises initiating an appeal process.
19. The non-transitory, computer-readable medium of claim 15 , wherein normalizing the information indicating the reason for the current status and processing the at least one record based on the normalized information indicating the reason for the current status and according to one or more workflows comprises applying a decision tree, wherein the decision tree comprises one or more branch nodes, each branch node representing a decision, and a plurality of leaf nodes, each leaf node representing a workflow.
20. The non-transitory, computer-readable medium of claim 19 , wherein the decision tree comprises at least one branch node representing a decision based on the information indicating the reason for the current status and at least one branch node representing a decision based on information from the at least one record.