Healthcare claim and remittance processing system and associated method

Abstract

A system for processing healthcare claims and remittances comprises a database and an electronic portal. The database contains previously received healthcare claims from a plurality of healthcare providers and previously received remittances from a plurality of payers. The electronic portal, connected to the database, receives a healthcare claim from a provider or a remittance from a payer, and splits the received claim or remittance into a plurality of data elements. The portal assigns a unique identifier and a shared identifier to each of the data elements of the received claim or remittance. The portal performs a duplicate claim edit and/or a third party liability edit on the received claim, or performs a duplicate remittance edit an/or a third party payment edit on the received remittance. Based on the result of the edits, the portal submits the received claim to a payer or submits the received remittance to a provider.

What is claimed is: 
     
         1 . A system for processing healthcare claims and remittances, the system comprising:
 a database containing previously received healthcare claims from a plurality of healthcare providers and previously received remittances from a plurality of payers; and   an electronic portal connected to the database, the electronic portal configured to receive a batch of healthcare claims from a healthcare provider and to split each received claim of the batch of healthcare claims into a plurality of data elements, the data elements comprising at least a patient identifier, a healthcare provider identifier, a date of service, and an amount payable;   the electronic portal further configured to determine if any necessary data is missing from the received claim and to send a missing data request to the healthcare provider;   the electronic portal further configured to perform a batch of duplicate claim edits and a batch of third party liability edits on the batch of received claims, wherein the third party liability edit comprises determining if one or more third party payers is responsible for paying at least a portion of the amount payable associated with the received claim, and wherein determining if the one or more third party payers is responsible for paying comprises at least one of (a) comparing an insurance carrier listed on the received claim to a stored list of insurance carriers that exclusively function as third party payers, and (b) searching the database for previously received healthcare claims corresponding to the same patient identifier as the received claim, and determining if any such previously received claims are associated with a third party payer; and   the electronic portal further configured to, based on the result of the duplicate claim edit or the third party liability edit, submit the received claim to a payer.   
     
     
         2 . The system of  claim 1 , wherein the electronic portal is further configured to assign one or more error codes to the received claim. 
     
     
         3 . The system of  claim 1 , wherein the third party liability edit further comprises determining if a third party liability indicator exists on the received claim. 
     
     
         4 . The system of  claim 1 , wherein the third party liability edit further comprises querying other previously received claims with the same patient demographic information that are stored in the database to determine if prior claims corresponding to the same patient identifier as the received claim involved third party liability. 
     
     
         5 . The system of  claim 1 , wherein the third party liability edit further comprises analyzing a diagnosis code included in the received claim in search of indications of third party liability. 
     
     
         6 . The system of  claim 1 , wherein the third party liability edit further comprises comparing the insurance carrier listed on the received claim against a database of insurance carriers who only handle third party liability claims. 
     
     
         7 . The system of  claim 1 , wherein the third party liability edit further comprises using standard patient eligibility inquiry and response transaction sets. 
     
     
         8 . The system of  claim 1 , wherein the electronic portal is further configured to receive a batch of healthcare claims from one or more healthcare providers. 
     
     
         9 . A method for processing healthcare claims and remittances, the method comprising:
 providing a database, stored in a memory device, of previously received healthcare claims from a plurality of healthcare providers and previously received remittances from a plurality of payers;   receiving a batch of healthcare claims from a healthcare provider;   splitting each received claim of the batch of received claims into a plurality of data elements, the data elements comprising at least a patient identifier, a healthcare provider identifier, a date of service, and an amount payable;   determining if any necessary data is missing from the received claim and sending a missing data request to the healthcare provider;   performing a batch of duplicate claim edits and a batch of third party liability edits on the received claim with a computer processing unit, wherein the third party liability edit comprises determining if one or more third party payers is responsible for paying at least a portion of the amount payable associated with the received claim, and wherein determining if the one or more third party payers is responsible for paying comprises at least one of (a) comparing an insurance carrier listed on the received claim to a stored list of insurance carriers that exclusively function as third party payers; and (b) searching the database for previously received healthcare claims corresponding to the same patient identifier as the received claim, and determining if any such previously received claims are associated with a third party payer; and   based on the result of the duplicate claim edit or the third party liability edit, submitting the received claim to a payer.   
     
     
         10 . The method of  claim 9 , further comprising receiving a batch of healthcare claims from one or more healthcare providers. 
     
     
         11 . The method of  claim 9 , further comprising assigning one or more error codes to the received claim. 
     
     
         12 . The method of  claim 9 , further comprising determining if a third party liability indicator exists on the received claim. 
     
     
         13 . The method of  claim 9 , further comprising querying other previously received claims with the same patient demographic information that are stored in the database to determine if prior claims corresponding to the same patient identifier as the received claim involved third party liability. 
     
     
         14 . The method of  claim 9 , further comprising analyzing a diagnosis code included in the received claim in search of indications of third party liability. 
     
     
         15 . The method of  claim 9 , further comprising comparing the insurance carrier listed on the received claim against a database of insurance carriers who only handle third party liability claims. 
     
     
         16 . The method of  claim 9 , further comprising using standard patient eligibility inquiry and response transaction sets. 
     
     
         17 . A computer program product for processing healthcare claims and remittances, the computer program product comprising at least one computer-readable storage medium having computer-readable program code portions stored therein, the computer-readable program code portions comprising:
 an executable portion capable of providing a database of previously received healthcare claims from a plurality of healthcare providers and previously received remittances from a plurality of payers;   an executable portion capable of receiving a batch of healthcare claims from a healthcare provider;   an executable portion capable of splitting each received claim of the batch of received claims into a plurality of data elements, the data elements comprising at least a patient identifier, a healthcare provider identifier, a date of service, and an amount payable;   an executable portion capable of performing a batch of duplicate claim edits and a batch of third party liability edits on the received claim, wherein the third party liability edit comprises determining if one or more third party payers is responsible for paying at least a portion of the amount payable associated with the received claim, and wherein determining if the one or more third party payers is responsible for paying comprises at least one of (a) comparing an insurance carrier listed on the received claim to a stored list of insurance carriers that exclusively function as third party payers; and (b) searching the database for previously received healthcare claims corresponding to the same patient identifier as the received claim, and determining if any such previously received claims are associated with a third party payer; and   an executable portion capable of, based on the result of the duplicate claim edit or the third party liability edit, submitting the received claim to a payer an executable portion capable of determining if any necessary data is missing from the received claim; and   an executable portion capable of sending a missing data request to the healthcare provider.   
     
     
         18 . The computer program product of  claim 17 , further comprising an executable portion capable of receiving a batch of healthcare claims from one or more healthcare providers. 
     
     
         19 . The computer program product of  claim 17 , further comprising an executable portion capable of assigning one or more error codes to the received claim. 
     
     
         20 . The computer program product of  claim 17 , further comprising an executable portion capable of determining if a third party liability indicator exists on the received claim. 
     
     
         21 . The computer program product of  claim 17 , further comprising an executable portion capable of querying other previously received claims with the same patient demographic information that are stored in the database to determine if prior claims corresponding to the same patient identifier as the received claim involved third party liability. 
     
     
         22 . The computer program product of  claim 17 , further comprising an executable portion capable of analyzing a diagnosis code included in the received claim in search of indications of third party liability. 
     
     
         23 . The computer program product of  claim 17 , further comprising an executable portion capable of comparing the insurance carrier listed on the received claim against a database of insurance carriers who only handle third party liability claims. 
     
     
         24 . The computer program product of  claim 17 , further comprising an executable portion capable of using standard patient eligibility inquiry and response transaction sets.