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Insurance Abstract
A system and method of submitting and processing health insurance
claims includes displaying a request for claim information to an
insured on a terminal connected to a network, entering the claim
information by an insured via the terminal, generating an identification
number associating the claim information with the health insurance
claim, storing the identification number and at least a portion
of the associated claim information on the network, and processing
the claim information stored on the network.
Insurance Claims
1. A method for submitting an insured's health insurance claim to
an insurer or a third party via a network and processing said claim,
comprising the steps of: displaying a request for claim information
to said insured at a terminal on said network; entering said requested
claim information by said insured via said terminal; generating
an identification number associating said claim information with
said health insurance claim; storing on said network at a location
accessible to at least one of said insurer and third party said
identification number and at least a portion of said claim information;
and processing said claim information stored on said network.
2. A method according to claim 1 further comprising the step of
storing said claim information on said network at a location accessible
to at least one of said insurer and insured as a historical record.
3. A method according to claim 1 wherein said health insurance
claim is initially submitted by said insured to said third party,
further comprising the step of said third party transmitting to
an insurer at least a portion of said claim information entered
by said insured and said identification number.
4. A method according to claim 1 further comprising the step of
printing a paper-based claim form including said identification
number and at least a portion of said claim information entered
by said insured, and mailing by the insured said paper-based claim
form and any additional documentation to said insurer.
5. A method according to claim 4 wherein said step of processing
said claim information comprises utilizing said identification number
to retrieve said claim information stored on said network.
6. A method according to claim 4 wherein said identification number
is in the form of a bar-code.
7. A method according to claim 4 wherein said step of processing
said claim information further comprises key verifying said claim
information stored on said network utilizing said additional documentation.
8. A method according to claim 4 wherein said step of processing
said claim information further comprises sending status notifications
to said insured during said processing.
9. A method according to claim 4 wherein said step of processing
said claim information further comprises enhancing said claim information
stored on said network.
10. A method according to claim 4 further comprising the step of
printing mailing instructions by said insured.
11. A method for generating a claim form for an insured's health
insurance claim comprising the steps of: displaying a request for
claim information to said insured at a terminal on a network; entering
said requested claim information by said insured via said terminal;
generating an identification number associating said claim information
with said health insurance claim; generating a claim form including
at least a portion of said claim information entered by said insured
and said identification number; and printing said claim form.
12. A system for submitting and processing a health insurance claim
comprising: a network; a storage location on said network; and an
insured's terminal on said network for displaying a request for
claim information, entering by the insured said requested claim
information, and for storing said claim information on said storage
location on said network.
13. A system as in claim 12 further comprising an insurer's terminal
on said network for accessing and processing said claim information
stored on said storage location.
14. A system as in claim 12 wherein said storage location is operated
by a third party.
15. A system as in claim 14 further comprising an insurer's terminal
coupled to said storage location operated by said third party such
that said third party may provide said insurer's terminal with said
claim information.
Insurance Description
FIELD OF THE INVENTION
[0001] The present invention relates generally to methods and systems
in the field of health insurance, and more particularly, to methods
and systems for submitting and processing health insurance claims.
BACKGROUND OF THE INVENTION
[0002] Health insurance reimbursement claims are presently submitted
to insurers on paper-based forms that are completed by the insured
claimants and usually mailed to the insurer. When a reimbursement
claim form is received by the insurer, the claim information contained
on the form is manually entered or transcribed into the insurer's
computer system by a data entry operator employed by the insurer.
[0003] Oftentimes errors occur when claim information is transcribed
incorrectly from the paper-based form into the insurer's computer
system by the insurer's data entry operator. The information most
commonly transcribed incorrectly includes the patient's name, the
date of service, the amount of claim, and the service provider information.
Payment is frequently mistakenly made to the provider instead of
to the insured. The incorrect transcription of the claim information
is not surprising since the information is generally complex and
the data entry operator is typically not motivated to exercise the
high degree of care and concentration necessary to avoid mistakes.
[0004] Errors also arise when subsequent submissions of claim information
are made by the insured in connection with an earlier submitted
claim. The subsequent submissions are not always correctly associated
with the earlier claim, for example due to an incorrect claim number
being designated on the subsequent submission.
[0005] As a result of these errors, the insured often receives
an incorrect reimbursement payment. The insured must then spend
a considerable amount of time corresponding with the customer service
department of the health insurance company via telephone or mail
in an effort to resolve the incorrect payment. Resolving the problem
can be a frustrating process for the insured.
[0006] Another problem inherent in a paper-based mail system for
processing health insurance claims is the relatively long time periods
that frequently pass before an insured is either advised of the
status of his or her claim, or the claim is acted upon.
[0007] Still another problem inherent in a completely paper-based
claim submission and processing system is that it is not uncommon
for the incoming claim form itself to become lost by the insurance
company or mail service, which usually results in hours of time
being wasted trying to locate the claim form.
[0008] A paper-based claim submission and processing system also
is expensive to maintain due in part to the high cost to the insurer
of manually transcribing or entering the information into the computer
system, the need to reprocess incorrect claims, and the high cost
of customer service support.
OBJECTS AND SUMMARY OF THE INVENTION
[0009] Accordingly, a primary object of the present invention is
to provide new and improved systems and methods for efficient and
accurate health insurance claim submission and processing.
[0010] Another object of the present invention is to provide new
and improved systems and methods for health insurance claim processing
in which claim information is entered into the insurance company's
computer system with greater reliability and accuracy than has been
the case heretofore.
[0011] Still another object of the present invention is to provide
new and improved systems and methods for health insurance claim
submission in which supporting documents, such as the examination
form signed by the doctor relating to a previously filed claim,
which are submitted to the insurance company subsequent to the initial
filing of the claims are reliably associated with the earlier filed
claim.
[0012] A further object of the present invention is to provide
new and improved systems and methods for health insurance claim
processing in which insurance claimants are provided with frequent
claim status notifications during the course of processing the claim.
[0013] Briefly, these and other objects are attained by providing
systems and methods for submitting and processing insurance claims
including the steps of displaying a request for claim information
to an insured on a network computer terminal and having the insured,
as opposed to an employee of the insurer, enter the claim information
via the terminal. Preferably, the method also includes the steps
of generating an identification number for association with the
submitted claim information, associating and storing the identification
number and at least a portion of the submitted claim information
in a network storage device, and then processing the claim information
stored on the network for payment of the claim.
[0014] The foregoing objects are also achieved by providing a system
for submitting and processing health insurance claims via a network
including a computer network, a storage location on the network,
and an insured's terminal on the network for displaying a request
for claim information, in response to which the requested claim
information is entered by the insured and wherein at least a portion
of the claim information entered by the insured is stored into the
storage location on the network.
[0015] The system and method for processing insurance claims can
be implemented by either an insurer or by a third party administration
company acting on behalf of at least one insurer.
[0016] In a preferred embodiment, a request for claim information
is displayed on a network terminal to which the insured has access.
The insured accesses the displayed request via the network terminal,
and enters the requested claim information himself or herself. An
identification number is generated at the time the claim information
is entered, and is saved on the network in association with at least
some of the claim information entered by the insured. The claim
information entered by the insured and saved in network storage
is accessible to the insurer or the third party at another terminal.
In the case of a third party, the claim information and the identification
number are transmitted to the insurer by the third party.
[0017] According to the invention, the possibility of error in
transcribing the information into the insured's computer system
is significantly reduced by having the claimant or insured enter
the data rather than a data entry operator employed by the insurer.
The insured is more familiar with the requested data and has a greater
incentive to accurately enter the data than does a data entry operator
employed by the insurer since an accurate transcription of the data
results in his/her claim being accurately and quickly processed
and paid. The insurer is saved the time and expense inherent in
having its employees transcribe the claim information into the insurer's
database from a paper-based form.
[0018] According to another aspect of the invention, the insurer
may also be requested to "key-verify" the claim information
before the information is stored at the storage location. Key-verification
virtually eliminates entry and omission errors in processing a health
insurance claim. The identification number allows the insurer to
quickly reference and retrieve the claim information from the network
where it was saved.
[0019] After entering the claim information, a paper-based form
is generated at the insured's computer terminal. The paper-based
claim form contains at least some of the claim information already
entered by the insured as well as the identification number generated
at the time the claim information was initially entered. In the
preferred embodiment, the identification number is in the form of
a bar code.
[0020] According to another feature of a preferred embodiment,
the insured then signs and mails or otherwise transmits the paper-based
claim form along with additional requested claim documentation to
the insurer. In a preferred embodiment, mailing labels with the
insured's address can also be printed by the insured. The mailing
labels may be used by the insured to mail the paper-based claim
form and additional documentation to the insurer.
[0021] Upon receipt of the paper-based claim form, the insurer
processes the claim by retrieving the stored claim information previously
entered by the insured from network storage by referencing the computer-generated
identification number. The identification number can be either manually
entered by the insured or scanned if a bar code is being utilized.
In the preferred embodiment, the insurer's data entry operator then
manually enters information from the additional documentation included
with the paper-based form or from other sources independent of the
insured's submission to key-verify the claim information submitted
by the insured. Key-verification prevents errors as well as fraud.
The claim information in the insurer's database can be enriched
by adding service information and internal codes. The claim can
then be evaluated for reimbursement.
[0022] According to a preferred embodiment of the invention, status
notifications are forwarded to the insured periodically during the
claim processing. In a preferred embodiment, e-mails including the
claim identification number are forwarded to the insured to confirm
that all claim information has been gathered, to confirm receipt
of the paper-based claim form and additional documentation, to request
correction of an error or omission, to confirm that the claim has
been accepted for reimbursement, and to inform the insured that
the reimbursement check has been mailed. These e-mail notifications
allow the insured to track the progress of processing the claim.
They are also used to identify problems immediately, such as the
failure of the insurer to receive the mailed paper-based claim form.
This in combination with the claim identification number provide
an efficient method for both the insurer and the insured to resolve
any problems during the processing of a claim.
BRIEF DESCRIPTION OF THE DRAWINGS
[0023] A more complete appreciation of the present invention and
many of the attendant advantages thereof will be readily understood
by reference to the following detailed description when taken in
conjunction with the accompanying drawings, in which:
[0024] FIG. 1 is a schematic view of a system for submitting a
health insurance claim to an insurer and for processing that claim,
according to the present invention;
[0025] FIG. 2 is a schematic view of a system for submitting a
health insurance claim to an insurer via a third party and for processing
that claim, according to the present invention;
[0026] FIG. 3 is a flow chart showing a method for submitting a
health insurance claim to an insurer according to the present invention.
[0027] FIG. 4 is an introductory screen used in an embodiment of
the present invention;
[0028] FIG. 5 is a registration screen used in an embodiment of
the present invention;
[0029] FIG. 6 is a login screen used in an embodiment of the present
invention;
[0030] FIG. 7 is a welcome screen used in an embodiment of the
present invention;
[0031] FIG. 8 is an insurance plan screen used in an embodiment
of the present invention;
[0032] FIG. 9 is a dependents screen used in an embodiment of the
present invention;
[0033] FIG. 10 is a providers screen used in an embodiment of the
present invention;
[0034] FIG. 11 is a claim screen used in an embodiment of the present
invention;
[0035] FIG. 12 is an e-mail notification of electronic claim submission
used in an embodiment of the present invention;
[0036] FIG. 13 is a compiled claim form screen used in an embodiment
of the present invention;
[0037] FIG. 14 is a filing instructions screen used in an embodiment
of the present invention;
[0038] FIG. 15 is an e-mail notification of mail receipt of claim
used in an embodiment of the present invention;
[0039] FIG. 16 is a key-verification and claim enrichment screen
used in an embodiment of the present invention; and
[0040] FIG. 17 is an e-mail notification of completion of processing
used in an embodiment of the present invention.
DETAILED DESCRIPTION OF THE INVENTION
[0041] Referring now to the drawings wherein like reference characters
designate identical or corresponding parts throughout the several
views, and more particularly to FIG. 1, a first embodiment of a
system for submitting and processing a health insurance claim is
generally designated 10. The system 10 is designed to be implemented
by a health insurance company (hereinafter "insurer"),
as opposed to a third-party provider.
[0042] The system 10 comprises a plurality of insured computer
terminals 12 connected through the Internet to an insurer's network
14 situated at the premises of the insurer 16. The insurer's network
14 includes a server 18 which runs the software and hosts a website
for implementing the method of the invention. The server 18 also
functions as a file server for document and data management and
storage for the insurer's computer terminals 20 on the network.
The insurer's computer terminals 20, which are generally operated
by data entry operators, are connected to the server 18 through
a hub 22 and switch 24 as is conventional.
[0043] According to the invention, individuals that have health
insurance policies with the insurer (hereinafter, "insured")
can access the website hosted by server 18 through the Internet
using standard personal computers which function as insured computer
terminals 12. Each insured computer terminal 12 also is connected
to a local printer which is used in connection with submitting health
insurance claims as described below.
[0044] Referring to FIG. 2, a second embodiment of a system in
accordance with the invention is generally designated 10a. System
10a is designed to be implemented by a third-party service provider
26 and provides claim services in accordance with the invention
to one or more insurance companies 16.sub.1, 16.sub.2 . . . . A
server 18a is situated on the premises of the third-party provider
26 and is connected to the insurer's computer terminals 20.sub.1,
20.sub.2 . . . situated at the premises of insurers 16.sub.1, 16.sub.2
. . . , respectively. Individuals having health insurance policies
with insurer 16.sub.1 can access the website hosted by server 18a
on behalf of insurer 16.sub.1 through the Internet from insured's
computer terminals 12.sub.1. Similarly, individuals having health
insurance policies with insurer 16.sub.2 can access the website
for insurer 16.sub.2 hosted on server 18a through the Internet using
insured's computer terminals 12.sub.2.
[0045] Generally, a system in accordance with the invention operates
as follows. An insured who desires to submit a claim to his or her
health insurance company accesses the insured's website hosted on
server 18 at an address provided by the insurer through the Internet
using an insured computer terminal 12. The website includes a screen
that prompts or requests the insured to enter certain general information
as well as certain information specific to the particular claim
being submitted. The insured enters the requested information via
his/her computer terminal 12. Prior to transmitting the data to
the server 18 the system generates an identification number unique
to the new claim being submitted and associates the identification
number with the claim data entered by the insured. The claim information
and associated identification number are sent over the Internet
to server 18 where the data is stored. The information is accessible
to the data-entry operators at insurer terminals 20 over network
14 for subsequent processing. The fact that according to the invention
it is the insured that enters the claim data into the insurer's
network rather than a data entry person employed by the insurer
as in the prior art greatly improves the likelihood that the data
is entered accurately. Not only can the insured enter the data more
slowly and carefully than the insurer's data entry operator, who
usually is responsible for entering the information for a large
number of claims in a short time period, but the insured has a much
greater incentive to accurately enter the claim data than does the
insurer's employee since it is the insured who will directly benefit
from an accurate entry of the data in the form of quick and efficient
processing of the claim.
[0046] Referring to FIG. 3 which shows a flow chart of the steps
of a method for submitting and processing health insurance claims
in accordance with the invention, initially, an insurer or a third
party provider hosts a website on the server 18 which requests claim
information from an insured desiring to submit a health insurance
claim. The insured uses the insured's terminal 12 to access the
website at an address, such as a URL, provided by the insurer. The
website contains a request for claim information which is displayed
on the insured's terminal 12 when the website is accessed. The request
for claim information may be completed online or downloaded onto
the insured's terminal 12 to be completed at a later time.
[0047] The first screen of the website, an example of which is
shown FIG. 4, provides a welcome to the website, instructions on
how to complete the claim forms and a format to log in and register.
The first time the insured uses the website, he or she must register
by creating a unique user ID and password. FIG. 5 shows a screen
that may be used to register the insured. The screen requests general
data including user identification information such as name, social
security number, and email address. The insured is also requested
to create a user ID and password. The insured is requested to confirm
the user ID, password, and email address to prevent typographical
errors.
[0048] The insured is required to use the user ID and password
each time the website is accessed to submit a new claim. An example
of a screen that may be used to log in to the website is shown in
FIG. 6. The insured is requested to enter the user ID and Password
previously created and click the Log In button. It is understood
that the insured may change the user ID and/or password. This can
be achieved by clicking the "Update your profile" button.
Also, if the insured forgets the user ID and/or password, there
is a procedure for gaining access to the previously stored user
ID and/or password. The log in screen may also contain a link to
the website's privacy policy and online usage policy. A cookie may
be placed on the insured's computer so that the insured is automatically
identified upon accessing the website.
[0049] Once the insured is logged in, an appropriate claim form
is accessed. There may be different forms for different types of
claims. Different insurance companies may require different forms.
Also, an insured may have previous claims that have not yet been
submitted. The desired claim form is chosen and may be completed
by the insured on-line using the insured's terminal 12. The insured
navigates through the website entering the various types of requested
claim information. The insured may not be required to enter all
the requested claim information. A menu screen (FIG. 7) is provided
on the website to navigate to the various requests for claim information.
The main menu contains a list of all actions the insured can take
in connection with submitting his or her claim. These actions include
updating or viewing the insured's personal information such as insured's
health insurance plan, dependents, and healthcare providers. Other
actions include filing a new or partially completed claim, viewing
prior claims, and logging off the website.
[0050] Upon clicking the link to update or view the insured's plan,
the insured is brought to the insured's plan screen. FIG. 8 is an
example of a insured's plan screen. At the insured's plan screen,
the insured enters plan information (e.g. name, address, date of
birth, social security number, telephone number, policy number,
etc.). The screen may also contain an option that allows the insured
to specify how reimbursement is to be received. Options may include
receiving reimbursement by mail via a check or by electronic payment
deposited directly to insured's specified bank account. A response
to a request for the insured's bank account information would also
have to be made with the latter option. This screen, as well as
several other screens, provides a menu with links to other areas
of the website which allows the insured to navigate directly to
a desired area of the website.
[0051] Upon clicking the dependents link, the insured's dependents
screen is accessed. FIG. 9 is an example of an insured's dependents
screen. This screen requests information regarding the insured's
dependents.
[0052] FIG. 10 is an example of an insured's health care providers
screen that is accessed by clicking on the providers link. This
screen prompts the insured to provide information regarding the
insured's doctors/providers.
[0053] It is understood that the foregoing personal information
(i.e. information regarding insured's plan, dependents, and providers)
may be permanently stored at the server 18 so that the insured may
retrieve the information at the website each time a new claim form
is completed and submitted. Additionally, the personal information
may be identified in drop down lists on other screens of the website.
[0054] The insured accesses the claim form by clicking on the claims
link of the new menu (FIG. 7). The insured may then select his or
her new claim in the case it is desired to submit a new claim or
a prior incomplete claim. FIG. 11 shows an example of a claim screen
which prompts the insured to enter certain claim information specific
to a new claim being made. The insured enters the patient name and
provider name. In a preferred embodiment, the patient and provider
names are chosen from drop down menus that are formulated based
on the personal information entered earlier by the insured. The
insured also enters data specific to the particular claim, the date
of treatment, e.g., amount of fee, type of treatment, any prescriptions,
etc. The screen provides for multiple claims to be made at the same
time.
[0055] When there is insufficient time, or when the insured does
not have all of the necessary information, to complete the form
in a single session, the partially completed forms can be stored
and saved at the storage location on server 18 for completion at
a later time. The partially completed claim form is saved for a
specified time period such as 30, 60 or 90 days, or any other desired
period of time. The insured will use his/her user ID and password
to sign-on to the system at a later time to complete the form.
[0056] After the insured finishes entering the requested claim
information, the insured is requested to review the claim form and
confirm that the information entered is correct. The insured can
make any necessary changes to the claim form. Once all of the basic
and specific information has been entered, and the insured is satisfied
that all of the information is correct, the insured submits the
claim form by clicking the "enter" button. The information
is transmitted to and stored on the storage location of server 18.
[0057] The claim information stored in server 18 is accessible
to at least the insurer. The claim information may also be accessible
to the insured as a historical record of the previous claims submitted
by the insured.
[0058] According to an important aspect of the invention, an identification
number is generated and associated with the claim information entered
by the insured. It is understood that the identification number
may be generated at any point after the first time the insured accesses
a claim form to immediately before the information is transmitted
and stored on the server 18. The identification number is ultimately
used by the insurer to identify and retrieve the claim information.
[0059] Where the server 18a (FIG. 2) is operated by a third party
26, a file is created for transmission to the insurer with claim
information and identification number, as will be discussed in further
detail below. The file remains pending until the paper based claim
form is received by the insurer as described below.
[0060] In a preferred embodiment, status notifications, preferably
in the form of e-mails, are automatically generated and sent to
the insured confirming receipt of the claim information submission
via the website. FIG. 12 is an example of an e-mail notification
of the electronic claim submission. The email contains some of the
claim information, such as the identification number, the service
provider, the amount of the claim, etc. The email may also contain
further instructions regarding claim processing.
[0061] In a preferred embodiment, the insured's terminal 12 is
used to generate a printed paper-based claim form containing at
least a portion of the claim information entered by the insured
and the identification number. The paper-based claim form may contain
the identification number in the form of a bar-code or in alphanumeric
format. The insured will print the claim form using the insured's
own computer printer to create a paper-based claim form. Preferably,
two copies of the paper-based claim form are printed so that the
insured may have a copy for the insured's records. The completed
claim form is printed with the bar code in such a format that facilitates
bar code scanning and retrieval of data related to that particular
claim form. It is understood that the claim form need not be printed
if the insurer does not require a paper-based claim form or a claim
form signed by hand.
[0062] An example of the printable claim form screen shown in FIG.
13. The printable claim form contains the bar code and claim number
as well as at least some of the personal information and claim information
provided by the insured. A signature line and date line are provided
for the insured to fill out once the paper-based form is created
by printing the printable claim form screen. A button is provided
which causes the printable claim form as well as filing instructions
and mailing labels to be printed. FIG. 14 is an example of filing
instructions. The filing instructions include mailing instructions
and a listing of other documentation required for reimbursement.
The mailing labels contain the address of the insurer for ease in
submitting the claim form.
[0063] The insured may sign and date the paper-based claim form
where indicated. Additional supporting documentation (e.g. healthcare
provider's invoices, lab work receipts, etc.) is attached and a
completed reimbursement claim package is sent by the insured to
the insurer using the mailing label and a mail service provider.
It is understood that where appropriate, the insured may scan the
signed claim form and additional supporting documentation and send
them to the insurer in an electronic form, such as in .pdf format.
Furthermore, it is understood that the insured need not send the
paper-based claim form nor supporting documentation if not required
to do so by the insurer.
[0064] Upon receipt of the paper-based claim form, the data entry
operator retrieves the previously entered claim data from server
18 by entering the identification number at a terminal 20 The data
entry operator can input the identification number manually into
the insurer's terminal 29, or in the preferred embodiment, the operator
can scan the identification number in the form of a bar code on
the paper-based form with a scanner coupled to the insurer's terminal.
Scanning the bar code provides a faster and error-free method of
inputting the identification number.
[0065] Once a paper-based claim form and any additional supporting
documentation are received by the insurer and the identification
number has been entered, an e-mail notification is sent to the insured
confirming receipt of the paper-based claim form. The e-mail notification
may be automatically generated. The insured's e-mail address may
be obtained from the claim information on the server 18. An example
of an e-mail notifying the insured that the paper-based claim form
has been received by the insurer is provided in FIG. 15. The email
contains some of the claim information, such as the identification
number, the service provider and the amount of the claim. The e-mail
may also contain information explaining the steps remaining in processing
the claim.
[0066] As discussed above, the data entry operator scans the identification
number from the paper-based claim form using the insurer's terminal
20 and retrieves claim information from the storage location of
server 18 associated with the identification number. The claim information
is displayed on the insurer's terminal 20.
[0067] In the preferred embodiment, the previously stored claim
information is key-verified by the data entry operator to confirm
its accuracy. The insurer does so by entering information at the
insurer's terminal 20 obtained from the supporting documentation
and paper-based claim form submitted by the insured or from independent
sources. An example of information gathered from independent sources
which may be used for verification is a record of service submitted
by the provider directly to the insurer. The claim information previously
entered by the insured is then verified by comparing the information
entered by the insurer to the information submitted by the insured.
FIG. 16 shows an example of a screen that may be used in the key-verification
step. The screen lists information that should be key-verified by
the data entry operator using the supporting documentation or other
information gathered independent of the previously submitted information.
The information may include insured's ID, insured's name, provider's
name, date of service, and amount of service.
[0068] If no discrepancy is found between the claim information
entered by the insured and the verification information, then the
claim is accepted for insurer payment calculation. If a discrepancy
is found, the insurer first ascertains whether the key-verification
information was entered correctly. If it is found that the claim
form is not filled out correctly or additional supporting information
is missing, the insurer may notify the insured by e-mail, regular
mail, and/or telephone that more information is necessary to process
the claim. In situations where the information entered by the insured
is clearly erroneous, a supervisor at the insurer may override the
entered information and change the entry. Key-verification insures
that the insured did not err or omit any information in filing the
claim. The use of key-verification also prevents insurance claim
fraud.
[0069] Additional information such as diagnosis codes and procedure
codes may be entered into database by the insurer using the insurer's
terminal 20 for each date of service to enrich the claim information.
The total amounts for all procedure codes for each date of service
must equal the total date of service amount in the claim. This data
is generally the insurer's internal data that assists in record
keeping or has other business functionality. FIG. 16 is an example
of a screen created by the software and displayed on the insurer's
computer terminal that can be used to enrich the claim information.
The screen requests input of procedure and diagnosis codes as well
as the amount for each procedure code.
[0070] Once the processing of the claim is completed, the insured
receives an e-mail notification informing the insured that the processing
is complete. The e-mail notification may be automatically generated.
The insured's e-mail address may be obtained from the claim information
stored in the server 18. An example of an e-mail notifying the insured
of completion of processing is shown in FIG. 17. The e-mail contains
some of the claim information, such as the identification number,
the service provider, the amount of the claim, etc. The e-mail may
also contain a link to an explanation of benefits (EOB) as well
as any payment due to the insured. The insured has the option of
viewing the EOB on the website which is indicated in the e-mail
notification. It is understood that an e-mail notification may be
sent at any point during the claim processing.
[0071] It is understood that the system 10 may also be used to
generate a health insurance claim form. A request for claim information
is displayed to the insured on the insured's terminal 12. The insured
enters the requested claim information using the insured's terminal
12. An identification number is generated associating the claim
information with the health insurance claim. A claim form is generated
including at least a portion of the claim information entered by
the insured and the identification number. Finally, the insured
uses a local printer to print the claim form.
[0072] Although the present invention is shown in FIGS. 1 to 17
with the system and method for submitting and processing a health
insurance claim described above, it is understood and within the
scope of the present invention that the features of the present
invention may be used with any health-related process that requires
submission of paper documentation for reimbursement or payment of
a claim, such as dental healthcare or prescription reimbursements.
Thus, the present invention is not limited to the specific features
and embodiments described above. |