Claim reimbursement valuation and remittance validation

US10546098B2 · kind B2 · utility

Assignee

• Passport Health Communications, Inc. · US

Inventor

• Richard Frank Derer · Clarendon Hills, US

Key dates

• Filing date: Dec 19, 2014
• Grant date: Jan 28, 2020
• Expiry date: Jun 14, 2037

Classification

• Technology area (CPC G): Physics
• CPC primary: G16H40/20
• WIPO field: IT methods for management
• WIPO sector: Electrical engineering

Abstract

A claim valuation engine is provided. The claim valuation engine enables a healthcare provider to accurately value an expected reimbursement of a claim from a payer based on a contract between the healthcare provider and the payer. Contract terms, code sets, fee schedules, and other valuation data is input into the engine. The engine receives a claim from a healthcare provider information system, locates a contract applicable for valuing the claim, correlates the claim attributes with the contract terms according to a hierarchy, and determines an expected reimbursement for each claim attribute or group of attributes. The claim valuation engine is further operable to determine contractual allowances, determine under and overpayments by validating remittances, and to simulate valuation of a contract by valuing a claim based on multiple sets of contract terms. The engine is further operable to generate output reports and post results to the healthcare provider information system.