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Insurance Abstract
An administrative support system and method for automatically processing
insurance claims is provided. The system includes data storage and
a processor, where the system retrieves data associated with an
insurance claim, identifies at least one issue associated with the
retrieved insurance claim data, analyzes the insurance claim data
and the at least one issue using at least one predefined condition
to determine whether issues can be resolved automatically, and automatically
resolves the analyzed insurance claim data having the associated
at least one issue meeting the at least one predefined condition.
The method includes retrieving data associated with an insurance
claim, identifying at least one issue associated with the retrieved
insurance claim data, analyzing the insurance claim data and the
at least one issue using at least one predefined condition to determine
whether issues can be resolved automatically, and automatically
resolving the analyzed insurance claim data having the associated
one or more issues meeting the at least one predefined condition.
Insurance Claims
1. A method for providing automated insurance claim processing comprising:
retrieving data associated with an insurance claim; identifying
at least one issue associated with the retrieved insurance claim
data; analyzing the insurance claim data and the at least one issue
using at least one predefined condition to determine whether the
at least one issue can be resolved automatically; and automatically
resolving the analyzed insurance claim data having the associated
at least one issue meeting the at least one predefined condition
when the insurance claim data can be resolved automatically.
2. The method of claim 1, wherein retrieving data comprises retrieving
previously adjudicated health insurance claim data.
3. The method of claim 2, wherein analyzing comprises analyzing
said previously adjudicated health insurance claim data to determine
whether the previously adjudicated health insurance claim data includes
missing data, incorrect data, or incomplete data.
4. The method of claim 2, wherein analyzing comprises analyzing
said previously adjudicated claim data to determine that a payment
associated with the retrieved previously adjudicated health insurance
claim has been completed.
5. The method of claim 1, wherein analyzing comprises analyzing
a reason code associated with the insurance claim data.
6. The method of claim 1, wherein analyzing further comprises determining
whether the retrieved insurance claim data can be substituted with
new claim data.
7. The method of claim 6, wherein determining that insurance claim
data can be substituted comprises determining that insurance claim
data is missing, incorrect, or incomplete.
8. The method of claim 1, further comprising generating a record
identifying the retrieved insurance claim and the at least one issue
associated with the retrieved insurance claim.
9. The method of claim 1, further comprising routing the analyzed
insurance claim data having the associated at least one issue meeting
the at least one predefined condition to an electronic work queue
when the issue requires manual resolution.
10. The method of claim 9, further comprising communicating data
required to resolve the at least one issue meeting the at least
one predefined condition in the electronic work queue.
11. A system for enabling automatic insurance claim processing
comprising: data storage for storing claims data to be processed;
and a processor for: retrieving data associated with an insurance
claim; identifying at least one issue associated with the retrieved
insurance claim data; analyzing the insurance claim data and the
at least one issue using at least one predefined condition to determine
whether the at least one issue can be resolved automatically; and
automatically resolving the analyzed insurance claim data having
the associated at least one issue meeting the at least one predefined
condition when the insurance claim data can be resolved automatically;
and routing the analyzed insurance claim data having the associated
at least one issue meeting the at least one predefined condition
to an electronic work queue when the insurance claim data requires
manual adjustment.
12. The system according to claim 11, wherein the retrieved data
is data associated with a previously adjudicated insurance claim.
13. The system according to claim 12, wherein analyzing comprises
analyzing the previously adjudicated insurance claim data to determine
whether there is previously adjudicated claim data that is missing,
incorrect, or incomplete.
14. The system according to claim 11, further comprising a graphical
user interface configured to display said retrieved claims data.
15. The system according to claim 14, wherein the graphical user
interface is associated with the electronic work queue and is configured
for manual claims adjustment for analyzed insurance claim data having
the associated at least one issue meeting the at least one predefined
condition that requires manual resolution.
16. The system according to claim 14, wherein the graphical user
interface configured to display substitutable claim data fields.
17. A computer-implemented software application that enables a
user to retrieve data associated with an insurance claim: identify
at least one issue associated with the retrieved insurance claim
data; analyze the insurance claim data and the at least one issue
using at least one predefined condition to determine whether the
at least one issue can be resolved automatically; and route the
analyzed insurance claim data for automatic resolution or for manual
adjustment.
Insurance Description
CROSS-REFERENCE TO RELATED APPLICATION(S)
[0001] The present invention claims benefit under 35 U.S.C. .sctn.
119(e) to U.S. Provisional Patent Application No. 60/738,433, filed
on Nov. 21, 2005; and also claims benefit to U.S. Provisional Patent
Application No. 60/748,620, filed Dec. 8, 2005, both of which are
herein incorporated by reference in their entireties.
FIELD OF THE INVENTION
[0002] The present invention relates to facilitating insurance
claim adjustments, by providing a method and system for determining
whether issues related to an insurance claim can be resolved automatically
and sending the automatically resolvable claims for automatic processing.
BACKGROUND OF THE INVENTION
[0003] Claims adjustment processes typically are manual processes.
As the number of individuals taking advantage of the opportunity
to defray the costs of health care and other liabilities by purchasing
insurance increases, the number of insurance claim adjustments grows
each year, and an overload of adjustment requests are received for
procession. In addition, manual adjustment processes are difficult
to monitor, trend, and manage, and may result in a loss of productivity.
SUMMARY OF THE INVENTION
[0004] In view of the drawbacks described above, the present invention
provides a system and method for reviewing previously finalized
claims needing adjustment to determine whether claims may be automatically
adjusted or manually adjusted via an electronic work queue. The
system and method may analyze one or more of the claim data, member
data, claim history, identified issues, categorization, and/or claim
destination, and as a result of analyzing, determine whether the
claim data may be automatically adjusted or requires manual adjustment
via an electronic work queue. Where the claim may be automatically
adjusted, the claim is routed to an automatic adjustment processor,
and where the claim requires manual adjustment, the claim is sent
to an electronic work queue. In one implementation, where a claim
has been paid to the wrong payee or provider, the claim has been
paid for the incorrect member or provider, there is a claim underpayment
or overpayment, or if a contract exception is identified, the analysis
of the claim data by the system may result in a determination that
the claim is in a condition for automatic adjudication. In another
example, the system may determine automatically that the claim data
is to be sent to an automatic readjudication system for resolution
when the system indicates that the claim was previously submitted
with incomplete, missing, or incorrect information.
[0005] In one such system and method, a computer application is
provided for analyzing claims to identify claim issues, e.g., reasons
the claim needs readjudication, and to determine whether the claim
issues may be automatically resolved or sent to an electronic work
queue for manual adjudication by a claims processor.
[0006] Another system and method involves providing a computer
application for analyzing claim issues to determine whether the
claim issues may be automatically resolved, and automatically reprocessing
the claim in order to reach a point of resolution. In a further
example, a grouping of claims that may be automatically resolved
may be grouped and sent for reprocessing together. This may be useful,
for example, where the same claim issue is present for a group of
claims. In yet a further example, where the claim or claims qualify
for automatic reprocessing, but fail the automatic reprocessing
process, the method further involves sending the claims for manual
adjustment.
[0007] In yet another system and method, a computer application
analyzes claim issues and routes the claim issues to an appropriate
electronic work queue for review and manual adjustment by a claims
adjuster.
[0008] The claims analyzed using the system and method of the present
invention may be previously adjudicated claim transactions. For
example, the previously adjudicated claims may be retrieved upon
a provider or member claim inquiry, or as a result of a system change
affecting a grouping of previously adjudicated claims. For example,
a previously adjudicated claim transaction that has been paid under
the wrong contract may be retrieved by a CCP upon a member or provider
inquiry, and the CCP may identify the appropriate claim issue code
corresponding to the reason the claim requires readjustment. Upon
issue identification, the system may analyze the claim transaction
data to determine whether the claim may be automatically resolved
using automatic processing, and if the claim data meets certain
conditions for automatic resolution, the claim data may be sent
to an automatic processing program or other work queue. In one example,
the claim data may be prepared for automatic resolution and maintained
in a database until it is retrieved by an automatic claims resolution
program. In further implementations of the invention, an automatic
claims processing/reprocessing system receives the prepared claim
data and automatically processes the claim to resolve the issue.
[0009] A method for providing automated insurance claim processing
includes retrieving data associated with an insurance claim, identifying
at least one issue associated with the retrieved insurance claim
data, analyzing the insurance claim data and the at least one issue
using at least one predefined condition to determine whether the
at least one issue can be resolved automatically, and automatically
resolving the analyzed insurance claim data having the associated
at least one issue meeting the at least one predefined condition
when the insurance claim data can be resolved automatically.
[0010] A system for enabling automatic insurance claim processing
includes data storage for storing claims data to be processed, and
a processor for retrieving data associated with an insurance claim,
identifying at least one issue associated with the retrieved insurance
claim data, analyzing the insurance claim data and the at least
one issue using at least one predefined condition to determine whether
the at least one issue can be resolved automatically, and automatically
resolving the analyzed insurance claim data having the associated
at least one issue meeting the at least one predefined condition
when the insurance claim data can be resolved automatically, else,
routing the analyzed insurance claim data having the associated
at least one issue meeting the at least one predefined condition
to an electronic work queue when the insurance claim data can not
be resolved automatically.
[0011] A computer-implemented software application, according to
certain implementations, enables a user to retrieve data associated
with an insurance claim, identify at least one issue associated
with the retrieved insurance claim data, analyze the insurance claim
data and the at least one issue using at least one predefined condition
to determine whether the at least one issue can be resolved automatically,
and route the analyzed insurance claim data for automatic resolution
or for manual adjustment.
[0012] In further implementations, the system includes an automatic
claims adjudication system for processing and reprocessing claims.
The system receives the claim data that qualifies for automatic
reprocessing and analyzes the data to determine whether reprocessing
the claim would resolve an overpayment or underpayment or whether
reprocessing the claim would result in no change. In some instances,
the automatic processing may determine that the data cannot actually
be reprocessed and directs the claim data to manual work queues.
[0013] The methods and systems for determining whether an issue
related to an insurance claim may be automatically resolved and
resolving the claim issue may apply for various types of insurance
including medical, life, liability, or property insurance.
[0014] These and other features and advantages of the present invention
will become apparent to those skilled in the art from the following
detailed description, wherein it is shown and described illustrative
embodiments of the invention, including best modes contemplated
for carrying out the invention. As it will be realized, the invention
is capable of modifications in various obvious aspects, all without
departing from the spirit and scope of the present invention. Accordingly,
the drawings and detailed description are to be regarded as illustrative
in nature and not restrictive.
BRIEF DESCRIPTION OF THE DRAWINGS
[0015] FIG. 1 is a diagram of an exemplary system for providing
automated claims processing.
[0016] FIG. 2 depicts a method for automatically reprocessing insurance
claim data that may be automatically processed.
[0017] FIG. 3 depicts one embodiment of a method for analyzing
claim data to determine whether a claim issue may be automatically
resolved.
[0018] FIG. 4 depicts an example screen shot of a desktop application
for facilitating automatic resolution of claim issues.
[0019] FIG. 5 is an illustration of a substitution table for facilitating
substitution of claim data.
DETAILED DESCRIPTION OF THE INVENTION
[0020] A system and method for automatically processing claims
may include a computer-implemented application for retrieving and
analyzing claim data to determine whether one or more claims may
be sent to an automated transaction generator where the claim may
be further analyzed to determine whether the claim may be automatically
adjudicated or be routed to an electronic work queue that presents
claim data in an adjustment format for manual adjustment. Processing
claims may involve determining whether claim changes were made from
the time the claim was originally processed to the time of request
for readjudication, or to the time of processing the request for
readjudication. In addition, claims may be processed, according
to certain implementations, by identifying one or more claim issues
or reasons the previously finalized claim requires readjudication,
and further processing the claim according to the type of readjudication
required.
[0021] The system, according to certain configurations, is arranged
at a front end as an administrative support application to provide
a customer care professional (CCP) with a user interface that enables
the CCP to document claim inquiries, such as claim adjustment inquiries.
The system integrates the documented claim information from a variety
of database sources, and determines whether the claim information
meets conditions that qualify it to be processed in an automated
transaction generator. Claim data meeting the requisite conditions
is sent to an automated transaction generator where the claim data
may be automatically adjudicated, e.g., may be automatically adjusted,
or where the claim data may be routed for manual adjustment. Claims
requiring manual adjustment may be presented to a back end of the
system in an electronic work queue in an adjustment format for manual
adjustment by a claims adjuster.
[0022] In some implementations, the system may facilitate conversion
of the data associated with the insurance claim into a suitable
form by reviewing and/or processing claim data and/or documentation
submitted by a CCP. For example, the system may correct claim data
that is incorrect, missing, or incomplete.
[0023] FIG. 1 provides a diagram of a system for providing an automated
claims processing method to enable the system and/or users to seamlessly
process previously adjudicated claims. The system includes an automated
transaction generator 101 that communicates (via secure communication
methods) with data storage component 102, one more a CCP user interface
103, an electronic work queue 104, and an automatic adjudication
system 105. Notably, the system may be implemented in a hub configuration
with the processor located at a central location, or may be implemented
as a distributed network of components. In addition, one or more
of the system components may be integrated into the automated transaction
generator. For example, the automated transaction generator may
operate as an automatic adjudication system.
[0024] FIG. 2 depicts an exemplary method 200 for automatically
processing an insurance claim. According to method 200, data associated
with an insurance claim is retrieved 210. Retrieval of insurance
data may be precipitated by a phone or online inquiry from a customer,
provider, or other party authorized to conduct business related
to the claim, may be retrieved based on a claims system change that
requires readjudication of a grouping of previously adjudicated
claims, or may be retrieved based on an uploaded file. Accordingly,
data retrieval requests may be via an administrative support system,
or via other software or electronic systems. The claim data retrieved
may be an entire record associated with the insurance claim, a partial
record associated with the insurance claim, or an entire claim history.
[0025] One or more issues related to the retrieved insurance claim
data are identified 220, and one or both of the retrieved insurance
claim data and the identified issues are analyzed 230 to determine
whether the issue can be submitted to an automated transaction generator
where the issue may be further analyzed to determine whether the
issue may be resolved automatically or sent to an electronic work
queue for manual resolution. Insurance claim data having one or
more issues that can be automatically resolved may be automatically
processed 240 in an automatic claim processing area, such as an
automatic claim adjustment system.
[0026] In one exemplary implementation, a CCP receives an inquiry
such as an incoming call from a provider or member regarding a member's
previously adjudicated claim. The CCP searches for and verifies
the member's identity, and prompts the system to retrieve information
related to the member's claims. The system displays the retrieved
information on a graphical user interface (GUI) or in printed or
electronic format for the CCP to review. For example, claims data
may be displayed based on the date of service associated with the
claim or in any other desired configuration.
[0027] According to this implementations, the CCP may select the
claim of interest via the GUI, and upon claim selection, the system
or the CCP may identify an issue associated with the claim that
needs resolving. For example, the claim may have been underpaid,
in which case the CCP identifies the underpayment issue on the GUI
by selecting a reason code corresponding to claim underpayment.
Alternatively, the system may analyze the claim data to identify
one or more issues and automatically assign a reason code to the
claim.
[0028] For example, FIG. 3 depicts an example screen shot 300 of
a desktop application a CCP may access where the reason code "adjustment
special circumstances" 310 is displayed. This type of reason
code for the claim inquiry may be the result of original claim data
having missing, incomplete, or incorrect information. In certain
instances, the system may automatically assign a reason code when
it retrieves claim data as a result of a CCP claim inquiry. However,
according to some configurations, a CCP may override the system's
default selection of the reason code and assign a new reason code
from a list box. Other examples of reason codes the system and/or
CCP may assign to a claim include that the claim was paid and processed
or that the claim requires adjustment. Depending on the reason code,
for example, the claim may be further analyzed to determine whether
the claim with its associated claim issue may be submitted to an
automated transaction generator for either automatic readjudication
or manual processing.
[0029] FIG. 4 depicts an exemplary method 400 for analyzing claim
data to determine whether a claim issue may be submitted to an automated
transaction generator for automatic resolution or manual resolution
via an electronic work queue. According to method 400, claim data
is required to meet one or more predefined claim conditions to be
suitable for submission to an automated transaction generator. Predefined
claim conditions may include a requirement that the claim payment
be complete 405, that the claim not have been previously routed
410, and/or that the claim not be a duplicate 415. If one or more
predefined conditions are not met, the claim may be sent for manual
adjustment 450. If each applicable condition, e.g., 405, 410 and
415 is met, then the claim may data may be further processed to
determine whether the issue associated with the claim is suitable
for processing by the automated transaction generator.
[0030] In method 400, if the claim issue is that the claim has
been paid to the wrong payee or provider 420, has been paid for
the incorrect member or provider 425, is an underpayment 430, is
an overpayment 435, and/or if a contract issue is identified 440,
then the claim is in a condition for submission automatic adjustment
445, and the claim may be forwarded to an automatic claims processing
system. This may be determined by examining a reason code on a GUI
that corresponds to an identified claim issue. Those skilled in
the art will understand that any set of one or more predefined conditions,
in addition to or as an alternative to the conditions of 420, 425,
430, 435, or 440, may be used in method 400 to sort claim data into
data that may be adjusted automatically and data that requires manual
adjustment. For example, if the claim issue is that the procedure
related to the claim was incorrectly coded, the claim may be sent
for manual adjustment 450. In another example, if the claim issue
is that the incorrect provider contract was loaded, that the provider
contract has been fixed, or that the claim is part of a group settlement,
then the claim may be sent to an automated transaction generator
where the claim may be automatically adjusted or presented to a
manual adjuster in an electronic queue in an adjustment format.
[0031] Claims suitable for processing by an automated transaction
generator may be routed to the automated transaction generator where
the claim data may be analyzed further to determine whether the
claim data may be submitted for automatic resolution, e.g., automatic
adjustment, or for manual adjustment via an electronic work queue.
[0032] When a the automated transaction generator, for example,
determines the claim may be automatically adjusted the claim data,
and in some instances, the associated record, described further
below, may be sent to an automatic adjustment system for automated
adjustment and reprocessing. In certain configurations, the automated
adjustment system reviews claim data and associated substitution
data and determines or verifies whether there was a claim overpayment,
underpayment, or no change in the claim allowable or payable. For
claims data having an underpayment, additional processing may allow
for the issuance of additional money to cover the deficiency. For
claims having an overpayment, additional processing may enable the
system to post overpayments. For claims having no change, additional
processing may enable the system to determine whether a member should
be provided with an explanation of their insurance benefits, for
example. In certain implementations, claim data suitable for automatic
processing and may be tested determine what the outcome of reprocessing
the claim data would be. If the reprocessing would result in resolution
of the issue, the system completes the transaction. In other implementations,
if the claim that qualifies for automated adjustment fails to automatically
adjust, the system may route the claim data to one or more work
queues for manual adjustment. For example, the system may route
the claim data to an electronic work queue for to be worked on by
an adjuster. The claim data may be routed to a specific electronic
work queue, for example, based on the reason the claim failed to
automatically adjust.
[0033] When a the automated transaction generator determines the
claim is not capable of being automatically adjusted, the automated
transaction generator routes the claim to an electronic work queue
for manual adjustment. Claim data may be presented to the manual
adjuster in an adjustment format that allows the adjuster to make
changes to the claim data. The system may present the adjuster with
information on the type of editing the claim data requires in order
to properly readjudicate the claim data. The manual adjuster may
review the claim data and any record generated by the system or
by a CCP as a result of an online or phone inquiry, for example.
[0034] According to another exemplary implementation, claim data
may be analyzed by the system to determine whether the claim data
may be substituted for new data. For example, the system may enable
manual data substitution when allowed via a special substitution
screen. If one or more of the substitution conditions is met, then
items in the claim may be substituted. In instances where it is
not appropriate for the claim to receive substitution data, the
system may route the claim data for manual adjustment or further
processing. In some implementations, claim data is not substitutable
by a CCP but requires substitution once it reaches the manual adjuster,
and a CCP instead may be provided with a comment field enabling
the CCP to enter a message that may facilitate the manual adjuster's
data substitution.
[0035] In some implementations, when substitution changes are to
be made by a CCP or a manual adjuster, the system may display a
substitution screen on the GUI. The substitution screen may be formatted
as a table showing an original data column, and an adjacent substitution
data column. The rows of the table may list a description of the
data (e.g., policy number, date of service, diagnosis code), the
original data (in the original data column), and a blank field (in
the substitution column) for substitution data to be filled-in by
the manual adjuster. FIG. 5 provides an exemplary substitution screen
that may have the original data column automatically filled in by
the system and in which the CCP or claim adjuster may enter substitution
data. By displaying the substitution screen in a table format, the
CCP or manual adjuster may view the original data while updating
incorrect, missing and incomplete claims data. In addition, the
table format enables the CCP or manual adjuster to verify easily
the changes with the member or provider.
[0036] In some configurations, the system may notify a CCP or manual
adjuster of issues identified by the system so that the manual adjuster
can review and/or correct the issue. The system also may provide
the CCP or manual adjuster with options for correcting the issue.
For example, a pull down menu or listing of items may be displayed
on the GUI for review and for selecting the appropriate data for
addressing the issue. The system additionally may provide check
boxes or a text box facilitating entry of substitution claim data
for the original claim data.
[0037] In a further configuration, the system determines that the
substitution can be performed automatically and substitutes the
appropriate claim data automatically. Alternatively, the claim data
and associated record, described further below, may be sent to an
automatic adjudication system for automated substitution, adjustment
and reprocessing.
[0038] For substitution of claim data, the types of claim data
that may be substituted may include, for example, claim level data
such as job number, provider data such as provider prefix, tax ID
number, and suffix, member data such as policy number, member number,
and relationship code, claim service level data such as service
code ranges (e.g., CPT and HCPCS codes), date of service, place
of service, and patient name, and claim header data such as diagnosis
code.
[0039] According to further implementations, for claims that meet
substitution conditions, the system further may analyze each item
in the claim in order to determine the specific items in the claim
data that may be substituted. For example, the system may identify
items that are incomplete, incorrect, or missing, and enable only
those items to have their original data substituted with new data.
[0040] In a further exemplary implementation, the system analyzes
the claim in order to determine what portion(s) of the data, if
completed, corrected or added, would result in the claim being capable
of automatic resolution, for example, via an automatic claim transaction
processing program.
[0041] The system may correct claim deficiencies to enable automatic
processing and resolution, and/or may prepare claims for automatic
or manual processing without correcting claim deficiencies. For
example, the system may flag that a claim issue is present and submit
the claim for automatic processing without adding new or corrected
claim data. In such a case, the claim issue may not be resolved
until after it is received and processed by an automatic claims
processing program. In another example, the system may flag a claim
issue and identify the possible claim edits and present the information
to a manual claims adjuster via an electronic work queue.
[0042] During the claim resolution process, when a claim is identified
as needing reprocessing and/or if substitution data is entered and
submitted, the system may document information related to the claim
such as inventory control number, date of service, provider, total
charge, substituted items and reason for the substitution. Furthermore,
the CCP may add other documentation related to the call. The system
may append the documentation data to its related claim, and may
tag the data as requiring readjudication or reconsideration. In
addition or alternatively, documentation may be saved in a table,
or stored as a stand alone file; and may facilitate resolution of
the claim issue, for example, by providing information related to
the type of issue associated with the claim and/or the type of processing
the claim issue requires in order to be resolved.
[0043] Documenting some or all of the data that the CCP and/or
claim adjuster is required to input into the system may reduce the
amount of time the CCP and/or claim adjuster spends creating records
and the chance of data errors. When the system identifies an issue
with the claim, the system automatically may document the issue
and any action taken by the system, CCP and/or claim adjuster to
resolve it.
[0044] In some implementations, additional data records may be
generated from the claim data and/or an appended record. For example,
an additional data record may be generated specifically for the
type of adjudication to be performed. For an automatic adjudication
system, an additional data record identifying a claim inventory
control number, check draft number, and original and substitution
data may be generated and stored as a stand alone file, appended
to the data associated with a previously adjudicated claim, stored
in an index or table, and/or stored in an "issue history"
portion of the record for the claim data. For manual adjustment
via an electronic work queue, a data record may be formatted so
that the record is displayed in appropriate fields on a manual adjuster's
adjustment work screen.
[0045] In some configurations, the claim and its processing or
reprocessing status may be reviewed by a CCP by recalling the claim
and, for example, viewing the history associated with the claim
and/or issue to be resolved. For example, the claim may be revisited
by a CCP to view the activity and/or status of the claim readjudication.
Thus, according to some implementations, the a claim record may
be updated to track the progress of the reprocessing of the claim.
[0046] According to certain configurations, claims adjudication
systems, such as those described in U.S. Pat. No. 5,359,509, having
an issue date of Oct. 25, 1994, and entitled "Health Care Payment
Adjudication and Review System", which is incorporated herein
by reference in its entirety, may be implemented along with the
disclosed inventive methods and systems.
[0047] An optional administrative support system includes one or
more CCP workstations coupled to a host system via, for example,
a network. The host system may be configured to communicate with
various databases and software and may operate in the manner disclosed
in U.S. Pat. No. 6,112,183, having an issue date of Aug. 29, 2000,
and entitled "Method and Apparatus for Processing Health Care
Transactions through a Common Interface in a Distributed Computing
Environment", which is incorporated herein by reference in
its entirety. For example, the host system may receive data related
to insurance claim transactions from a variety of data formats,
compression types, encryptions, native languages, countries of origin,
or operating environments of origin, process the data to generate
an interface definition language, and provide the processed data
to a CCP workstation configured as a common interface structure
for processing the insurance claim transactions. This allows the
CCP to field inquiries regarding insurance claim transactions and
retrieve the necessary information to address the issue or direct
the claim transaction data to the appropriate processing area.
[0048] Furthermore, an application for automatic claim processing
may be combined with additional customer service applications such
as the one disclosed in U.S. Pat. No. 6,581,067, having an issue
date of Jun. 17, 2003, and entitled "Method and System for
Providing Administrative Support", which is herein incorporated
by reference in its entirety.
[0049] It should be understood that the method and system according
to the present invention may be implemented using various combinations
of software and hardware as would be apparent to those of skill
in the art and as desired by the user. The present invention may
be implemented in conjunction with a general purpose or dedicated
computer system having a processor and memory components.
[0050] From the above description and drawings, it will be understood
by those of ordinary skill in the art that the particular embodiments
shown and described are for purposes of illustration only and are
not intended to limit the scope of the present invention. Those
of ordinary skill in the art will recognize that the present invention
may be embodied in other specific forms without departing from its
spirit or essential characteristics. References to details of particular
embodiments are not intended to limit the scope of the invention.
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