System for processing healthcare claim data

[0001] This is a non-provisional application of provisional application serial No. 60/371,027 by D. Fitzgerald et al. filed Apr. 9, 2002 and of provisional application serial No. 60/384,487 by D. Fitzgerald et al. filed May 31, 2002.

FIELD OF THE INVENTION

[0002] This invention concerns a system and user interface for acquiring, validating and processing claim data for payment for provision of services to patients by a healthcare provider, for example.

BACKGROUND OF THE INVENTION

[0003] An important function performed by healthcare providers (such as hospitals, clinics or physicians) is the sending of claims to healthcare payer institutions to obtain reimbursement for provision of services to a patient. These claims may be in electronic or paper format. Paper claims typically go through a data entry process that converts them to an electronic format. The entered electronic claims are usually sorted, indexed and archived. Each claim is processed in a payer institution adjudication system. The payer adjudication system interprets the claim data and determines whether or not the claim is to be paid in full, partially paid or denied. This adjudication process may be fully automated, partially automated, or manual. The results of claim adjudication may include the issuance of a check and an explanation of benefits (EOB) to the insured and healthcare provider, or a request to send additional information. The process of reviewing claims is labor-intensive and error-prone.

[0004] Known adjudication systems help payers and providers streamline their claims payment and medical case management processes. A typical adjudication system employed by a payer institution, may use high speed scanning equipment and optical character recognition software to translate paper claims into electronic data. The electronic claim data is processed by rule based software to interpret the claim data for any conflicts. Conflicts are usually reported to a user either as an online claim image with areas of concern highlighted, or as a report. A typical adjudication system employed by a healthcare provider evaluates electronic claim data before it is submitted to a payer institution. Healthcare providers do their best to ensure claims are accurate before they send them to the payer by embedding payer rules into their software applications or by utilizing “claim scrubbing” applications to evaluate claim data prior to submission to the payer. Known systems also approach claim data processing from a piecemeal perspective whereby, for example, one software vendor system addresses online eligibility and electronic remittance and a different vendor system addresses revenue management from a physician perspective. Another vendor system supports claim editing, but only after the claim is generated. Further known systems require significant user intervention once a claim is produced. Known systems fail to approach claims processing and management from a combined payer, provider and patient perspective. Another problem with known processes is that rules used by a healthcare provider may be inaccurate, obsolete, or comprise an incorrect version or may otherwise be different to those in current use by a target payer institution. Further, known systems typically do not address compatibility of healthcare provider and payer systems. This results in claims that fail the edit process upon receipt by the payer and consequent disallowance by the payer. Disallowed claims cause delayed payment and negatively impact healthcare provider cash flow and patient satisfaction with the process. A system according to invention principles improves claim accuracy prior to claim submission to a healthcare payer institution.

SUMMARY OF INVENTION

[0005] A claim pre-processing system employs trial adjudication to improve claim accuracy prior to claim submission to a healthcare payer institution or other entity. A system processes claim data related to provision of healthcare to a patient The system includes a claim data collator for collating data related to a claim for a particular patient for submission to a payer and a source of rules for use in processing collated claim data. A pre-processor submits the collated claim data for processing using the rules to validate the collated claim data is in condition for processing to initiate generation of payment. A claim processor submits the collated claim data to a payer, in response to successful validation by the pre-processor.

[0006] In a feature of the invention the system includes a rules processor for processing acquired claim data to identify a condition triggering application of a different set of rules for determining validity of an individual claim element.

[0007] In another invention feature the pre-processor re-submits amended collated claim data for processing using the rules to validate the collated claim data is in condition for processing to initiate generation of payment, the amended collated claim data being received in response to unsuccessful validation using the rules.

BRIEF DESCRIPTION OF THE DRAWING

[0008]FIG. 1 shows an overall claim processing system employing trial adjudication to improve claim accuracy prior to claim submission to a healthcare payer institution or other entity, according to invention principles.

[0009]FIG. 2 shows a trial adjudication system used in the overall claim processing system of FIG. 1, according to invention principles.

[0010]FIG. 3 shows a flowchart of a process employed in claim processing by the systems of FIGS. 1 and 2, according to invention principles.

[0011]FIG. 4 shows a user interface display image illustrating a patient claim billing record for multiple patient encounters with a healthcare provider concerning treatment of an injury, according to invention principles.

[0012]FIG. 5 shows a user interface display image illustrating a record for a particular patient claim, according to invention principles.

[0013]FIG. 6 shows a user interface display image illustrating claim preprocessing results and identifying claim rejection reasons by description and rejection code, according to invention principles.

[0014]FIG. 7 shows exemplary rules and associated error code results of applying rules to patient claim data, according to invention principles.

[0015] FIGS. <b>8</b>-<b>14</b> show data records including data elements incorporated in a central data repository used in claim processing, according to invention principles.

DETAILED DESCRIPTION OF INVENTION

[0016]FIG. 1 shows an overall claim processing system employing trial adjudication to improve claim accuracy prior to claim submission to a healthcare payer institution or other entity. In the FIG. 1 system, continuously updated centralized common rules in repository <b>74</b> are employed to ensure that individual healthcare providers, as well as individual healthcare payer institutions are working with the most up-to-date version of the rules. Use of centralized rules ensures that a healthcare provider is able to comply with the latest provisions of the rules. A rule as used herein comprises a procedure for determining that healthcare claim elements comply with predetermined requirements including, health plan reimbursement conditions, health plan format requirements, a reimbursement formula, reimbursement constraints and a reimbursement computation procedure. A rule also may comprise a prescribed guide, a precept, or a model for how to present, conduct or regulate an action by using a form and data or the relations between form and data. Further, an exception as used herein encompasses the identification of an issue and mechanism to process that issue.

[0017] The FIG. 1 system automates the pre-registration, eligibility, registration authorization, claim generation, trial adjudication, claim submission, payment remittance, and post-remittance processes of a health care claim data processing cycle to provide seamless, accurate and prompt processing. The system automates coordination of employer and payer activities and ensures that pre-visit enrollee data is accurate. Thereby, if a patient uses a consumer portal (<b>24</b>) to schedule a visit or if a healthcare facility collects insurance information from a patient, medical necessity, referral and eligibility verification processing is automatically initiated. A claim is evaluated for accuracy and edited by a rule execution function <b>46</b> and adjudication unit <b>48</b>, using the applicable rules in rules repository <b>74</b>, both before the claim is completed (i.e. as individual claim elements for individual healthcare encounters post to the claim, for example) and again before the completed claim is submitted for payment. A variety of portals <b>20</b>-<b>28</b> in the FIG. 1 system are controlled and administered by interface <b>10</b> to provide claim data access to patients, payers, providers, employers and government agencies. The system facilitates healthcare provider compliance with governmental and payer rules through use of automated, rules-based editing and review systems.

[0018] The FIG. 1 system automatically edits claim data to ensure claims are error free. The system advantageously performs claim trial adjudication (pre-processing) using the rules to validate that edited collated claim data is in condition for submission for actual adjudication by a payer institution to initiate generation of payment. Thereby incidence of partial or complete claim rejection is reduced which correspondingly reduces operational costs for both the providers and payers. Payers are enabled to efficiently increase the daily volume of claims processed, since claims are accurate and electronically received. This also reduces the volume of inquiry phone calls from providers and patients concerning insurance coverage and claim matters. Providers benefit through a shortened revenue cycle resulting in quicker remittance payments, reduced staff intervention and improved patient satisfaction. A failure in trial adjudication automatically initiates deficiency correction or manual intervention via scheduling of a worklist task to be performed by expert personnel. Upon successful trial adjudication, the claim data is automatically re-queued for electronic submission to the payer. Payment advice is processed electronically without manual intervention and automatically posted to the appropriate account.

[0019] The FIG. 1 system comprises functions implemented in software applications and executable procedures for processing claim data. These functions may also be implemented in hardware or a combination of both hardware and software resident in one or more computer systems and servers and involving one or more communication networks for internal and external communication. The system processes claim data related to provision of healthcare to a patient by collating data related to a claim for a particular patient for submission to a payer. The collated claim data is submitted for pre-processing using rules to validate the collated claim data is in condition for processing to initiate generation of payment. Upon successful validation the validated claim data is submitted to a payer. The claim data is collated by data acquisition unit <b>32</b> via interface <b>10</b> for storage in data repository <b>68</b>. Repository <b>68</b> contains financial and clinical data related to healthcare encounters that are currently ongoing. Data acquisition unit <b>32</b> is able to receive both solicited and unsolicited data from multiple different sources and to request data from these sources via interface <b>10</b>. The different sources include external users (participants) subscribing to and using the FIG. 1 system and may include for example, healthcare providers, healthcare payer institutions (e.g. insurance companies, Health Maintenance Organizations—HMOs etc.), consumers, employers, and government agencies.

[0020] Data keeper unit <b>64</b> acts as a gateway and data management system governing data storage and retrieval for healthcare data repository <b>68</b> and processing requests to use repository <b>68</b> to store, modify, and retrieve data. Data keeper unit <b>64</b> also tracks data changes in repository <b>68</b> by recording time, date and nature of changes made as well as the source and identity of the author of the changes to maintain a data update audit trial. Historian unit <b>70</b> is used in archiving and maintaining older data value versions and is specifically used in archiving data records associated with patient encounters following completion of financial transactions (i.e. encounters for which no related financial transactions are outstanding) and processing for these encounters. An encounter as used herein comprises a patient encounter with a healthcare enterprise involving patient and healthcare enterprise interaction that has a financial or transaction consequence and may include for example a patient visit, phone call, inpatient stay or outpatient treatment etc. Records of such encounters are maintained by data keeper unit <b>64</b> in repository <b>68</b>. Historian unit <b>70</b> stores archived data in archive (data warehouse) database <b>72</b>.

[0021] The collated claim data is submitted for pre-processing by trial adjudicator <b>48</b> using rules to validate the collated claim data is in condition for processing to initiate generation of payment. Trial adjudicator <b>48</b> initiates execution of a sub-set of rules executed by rule execution unit <b>46</b>. Unit <b>46</b> detects the occurrence of an event triggering application of associated rules and executes the rules associated with that event. An event may include receipt of data to add to the repository <b>68</b>, a request to execute a specified list of rules, and an event triggered by the activities of a function within the FIG. 1 system. A rule executed by unit <b>46</b> may itself generate a triggering event and initiate execution of other rules. An individual rule may contain a test resulting in assignment of a result status of “True” or “False” upon execution of a rule. An individual rule may also contain lists of actions to be performed upon a true result and alternate actions to perform upon a false result, for example. The list of actions may include, creation of worklists of tasks for automatic or manual performance, creation of logs and audit reports and accounting reports, creation of error reports, generation of claims, posting of remittances, modification of data, and other actions. Data Morpher unit <b>44</b> comprises a sub-category of actions that rules invoke to modify data in repository <b>68</b> in response to command. Unit <b>46</b> also processes and executes rules stored in the Relationship Rules Repository <b>18</b> that contains rules required and used by the Protector <b>12</b>, Translator <b>14</b>, and Transporter <b>16</b> during communication involving interface <b>10</b>.

[0022] The rules executed by trial adjudication unit <b>48</b> determine expected adjudication results when a specified set of claim data is submitted to a specified payer. Unit <b>48</b> uses rules derived from repository <b>74</b> (or from rule accessor <b>52</b>) via rule keeper interface <b>66</b> to predict the result of submitting a specified set of claim data to a specified payer. For this purpose the rules used by unit <b>48</b> replicate the rules used by the selected specific payer. Unit <b>48</b> identifies conditions that would lead to denial of payment and enables such conditions to be fixed (automatically or with manual intervention) before a claim is submitted to a designated payer. This procedure advantageously facilitates the creation of error-free claims using rules derived from repository <b>74</b> or using remotely accessed rules. Rules including regulatory guidelines and directives are continuously acquired for storage in repository <b>74</b> and are continuously updated and maintained in this repository via rules keeper unit <b>66</b>. Rules archiving unit <b>76</b> in conjunction with unit <b>66</b>, dates and time stamps rules to be archived and stores obsolete, expired or older version rules in archive (rules warehouse) database <b>78</b>. Archived rules are accessible and usable to determine an outcome based on submission of particular claim data for adjudication using rules in force at a date in the past, for example. Repository <b>74</b> contains adjudication rules acquired from payer institution participants and rules that are established from previous transactions with payers. Repository <b>74</b> also contains rules developed by the system and by authorized participants that add automated processes to the system. Pattern designer unit <b>38</b> creates specialized rules that define surveillance research processes and rule maker unit <b>56</b> is used to create general purpose rules.

[0023] Unit <b>48</b> uses rules in repository <b>74</b> derived from external rule sources (such as rules <b>62</b> owned by a payer institution <b>60</b>) by rule accessor <b>52</b> via interface <b>10</b> and data network <b>58</b>. Network <b>58</b> may comprise a conventional network such as LAN (local area network), WAN (wide area network) or the Internet or alternatively may comprise a network service such as a clearinghouse or other service used by a healthcare payer or a healthcare provider to facilitate data and rule (e.g., payer rules <b>62</b>) acquisition for claim adjudication. Payer rules <b>62</b> are rules promulgated by a payer <b>60</b> that are not accessible through the automated process managed by Rule acquisition unit <b>54</b>. Rather rules <b>62</b> are manually determined through manual acquisition processes and are parsed and analyzed by Rule acquisition unit <b>54</b> by using a user interface provided by rule maker unit <b>56</b>. The Rule Maker <b>56</b> user interface supports manual creation, review and update of rules including those acquired via unit <b>54</b>. Unit <b>56</b> also prompts a user with lists of available tests and actions and guides the user through the process of constructing and editing rules prior to storing the edited rules in Rules Repository <b>74</b>.

[0024] Rule acquisition unit <b>54</b> accumulates rule data by automatic interrogation of payers systems for rules and through documentation and other information provided by payers that do provide access to their proprietary programmed rule sets. Unit <b>54</b> retrieves payer generated information bulletins from payer websites and other sources and analyzes this material to identify information representing new or changed rules for incorporation in repository <b>74</b> and to identify rules that have expired. Further, individual payer institutions may use Payer Portal <b>22</b> to communicate rule information via interface <b>10</b> to acquisition unit <b>54</b> which incorporates them using rule keeper unit <b>66</b> in repository <b>74</b>. Unit <b>54</b> also receives new rules following user manual data entry and processing via a user interface provided by rule maker <b>56</b> based on information acquired from payers by rules gatherer service <b>80</b>. Payers forward updated rule information to service <b>80</b> in advance of implementing a new rule or rule version, for example. Service <b>80</b> supports user creation of implementable definitions of these new or updated rules using Rule Maker user interface <b>56</b> for incorporation in rules repository <b>74</b>. Service <b>80</b> also monitors claim rejection issues and rates of adjudication success and failure and supports adjustment or creation of rules to resolve identified issues. Rule Checker unit <b>50</b> monitors rules in repository <b>74</b> and identifies and indicates to a user those rules that are incomplete or contain incorrect syntax. Unit <b>50</b> also reports combinations of rules that are mutually inconsistent. Further, in response to identification of a predetermined exception condition during claim data processing by rule execution unit <b>46</b> and trial adjudication unit <b>48</b>, exception tracker function <b>42</b> employs a sub-set of rules managing the processing and reporting of an identified exception condition. Exception tracker function <b>42</b> may be invoked by rule execution unit <b>46</b> in response to execution of a particular rule or upon a particular result of executing a rule. Upon determination of an exception condition, function <b>42</b> may schedule manual intervention, via a user interface or a worklist or by communicating a report or message to a recipient, for example.

[0025] Trial adjudicator <b>48</b> uses rule accessor <b>52</b> to submit claim data for trial adjudication by remotely located rules. These remotely located rules may be maintained (and owned) by a different entity (such as a payer institution) to the owner of the FIG. 1 system. A payer who owns such rules establishes a procedure for receiving claim data for trial adjudication and responds with a report indicating how the submitted claim data would be adjudicated using the payer owned rules.

[0026] Claim data used for trial adjudication and ultimately submitted to a payer upon amendment (if required) and validation is derived from data repository <b>68</b>. FIGS. <b>8</b>-<b>14</b> show an exemplary data record structure for data elements incorporated in central data repository <b>68</b> and used in claim processing. Specifically, FIG. 8 shows a partial patient record data structure, FIG. 9 shows a medical record data structure and FIG. 10 shows a partial payer record data structure. A charge record data structure and occurrence code data structure are presented in FIGS. 11 and 12 respectively and FIGS. 13 and 14 indicate a span code (for use in identifying service charges that are to be grouped on a single claim) and a medical condition code data structure respectively. These record structures are exemplary only and repository <b>68</b> typically contains other types of records associated with claim data such as, for example, records concerning ambulance services, rehabilitation services, treatments and other services and activities. The record structures of FIGS. <b>8</b>-<b>14</b> are individually accessible in repository <b>68</b> using a claim packet identifier (<b>800</b>, <b>900</b>, <b>920</b>, <b>940</b>, <b>960</b>, <b>980</b>, <b>830</b>), section identifier (<b>802</b>, <b>902</b>, <b>922</b>, <b>942</b>, <b>962</b>, <b>982</b>, <b>832</b>) and sequence number (<b>804</b>, <b>904</b>, <b>924</b>, <b>944</b>, <b>964</b>, <b>984</b>, <b>834</b>).

[0027] Data in an individual record data structure is field length delimited. In the patient record structure of FIG. 8, for example, a patient last name (<b>806</b>) occupies a fixed length of <b>20</b> characters, followed by a patient first name (<b>808</b>) occupying twelve characters and middle initial (<b>810</b>) occupying one character. The record structures of FIGS. <b>9</b>-<b>14</b> contain data related to other particular claim data aspects in similar predetermined fixed length fields. The medical record of FIG. 9, for example, contains an admission diagnosis code (<b>906</b>), as well as a primary diagnosis code (<b>908</b>) and other diagnosis codes (<b>910</b>). The payer record of FIG. 10 contains a source of payment code (<b>926</b>), as well as payer identifier (<b>928</b>) and payer sub-identifier (<b>930</b>). The charge record of FIG. 11 contains a service charge code (<b>946</b>), as well as a service charge revision code (<b>948</b>) and service date (<b>950</b>). The occurrence code record of FIG. 12 contains an occurrence identification code (<b>966</b>) and occurrence date (<b>968</b>). The span code record of FIG. 13 contains a span identification code (<b>986</b>), as well as a span determination start date (<b>988</b>) and end date (<b>990</b>) for use in identifying codes and the related dates that identify an event that relates to the payment of this claim. The condition code record of FIG. 14 contains a medical condition identification code (<b>836</b>). The items referred to in connection with FIGS. <b>8</b>-<b>14</b> are described for exemplary purposes. However, other record items are shown in the record structures of FIGS. <b>8</b>-<b>11</b>. These other items are representative of the breadth of data that may be included in the various records in the repository <b>68</b> structure, for example. In an alternative embodiment, other non-fixed length data record structure or another data record structure may be employed for repository <b>68</b>.

[0028] The claim data in repository <b>68</b> is collated by data acquisition unit <b>32</b> via interface <b>10</b> from multiple different sources as previously described and stored in repository <b>68</b> via data management system <b>64</b>. A data emitter unit <b>34</b> provides claim data to an external entity (e.g., portals and participants <b>20</b>-<b>30</b>) by extracting required claim data from repository <b>68</b> and communicating it via interface <b>10</b>. Data reacher unit <b>36</b> is used by functions of the FIG. 1 system to provide read-only access to claim data stored by a remote entity and to make decisions based on this data. Further, claim data repository <b>68</b> is searchable by users <b>30</b> via external portals <b>20</b>-<b>28</b> using data search criteria created using search pattern design function <b>38</b>. Thereby a user may search for statistically significant data patterns and other data patterns in analyzing the claim data in repository <b>68</b>.

[0029] Search design function <b>38</b> employs a specialized category of rules stored in rules repository <b>74</b>. An authorized user is able to use surveillance portal <b>28</b> via interface <b>10</b> to use the specialized category of search rules to support a search of rules and claim data information. Searchable information sources include rules repository <b>74</b>, relationship rules repository <b>18</b> as well as claim data repository <b>68</b>. For this purpose, search pattern evaluator function <b>40</b>, employs a sub-set of rules executed by rule execution unit <b>46</b> to process a definition of a pattern search created by pattern design function <b>38</b>. Specifically, pattern evaluator function <b>40</b> identifies patterns in the data searched according to action steps included in the search definition and reports results to the search initiator via interface <b>10</b>. A pattern search is executable in response to occurrence of an event. An event may include, for example, a command (in response to a request by a participant), or upon detection of a change in particular data (receipt of a specific diagnosis, for example) or an event may be internally generated such as in response to expiration of a particular time period.

[0030] Interface <b>10</b> provides access by various interested participants <b>30</b> in the claim data processing operation via portals <b>20</b>-<b>28</b> for searching, viewing or initiating actions. Thereby a participant (such as a healthcare provider, payer institution representative, patient, employer or government agency) is able to access claim data, payer rules and initiate various actions such as a data correction action, for example. Specifically healthcare providers and healthcare payer representatives are able to access the system via portals <b>20</b> and <b>22</b> that provide the functions these entities respectively require. A healthcare provider, for example, is able to input financial data and associated clinical data into repository <b>68</b> and to initiate and manage claim trial adjudication and other rule-driven processes via portal <b>20</b>. Similarly, a provider is able to automatically modify its own data based on automated rules or through manual amendment and update. A provider is further able to initiate submission of validated error-free claims for payment and to initiate claim status inquiries. In addition, a provider via portal <b>20</b> is able to acquire remittance advice (i.e., information about payments made) and to automatically post acquired advice to corresponding correct accounts as well as to generate and submit secondary and tertiary claims and obtain worklists (of tasks to be performed) and reports in support of management of its business.

[0031] A payer institution is able to use portal <b>22</b> to store and maintain adjudication rules in repository <b>74</b> and to receive claim data for trial or actual (determinative) adjudication as well as to respond to claim status inquiries. A payer is further able to communicate a request for information or issue remittance advice and obtain worklists and reports and manage its business and revenue cycle. A consumer, such as an individual patient, covered dependent or healthcare plan subscriber with appropriate authorization is able to use consumer portal <b>24</b> to view his own claim data records and claim status and research rules governing payment. A consumer is also able to correct errors in his own demographic data or medical record and to schedule appointments via the system. A consumer is also able to obtain account balance, recent transaction records, future deposit information and request payment from a medical expense reimbursement account for items paid out of pocket.

[0032] An employer, or another plan administrator, is able to use portal <b>26</b> to manage healthcare encounter cycle business and to negotiate healthcare contracts on behalf of a group of persons (employees) and to monitor activity related to those employees. For this purpose, an employer is able to obtain, for example, a worklist or a report identifying incidence of various diagnoses, utilization of various providers, a breakdown of charges (e.g. those paid by members, contractually reduced, or denied). Thereby an employer is able to determine if plan members would benefit from an alternative health plan selection. Surveillance portal <b>28</b> enables authorized participants <b>30</b> (e.g. a regulator or researcher) to create and implement research projects to analyze stored claim data by searching for patterns or trends in the claim data of repository <b>68</b> in conjunction with rules repository <b>74</b>. Specifically, surveillance portal <b>28</b> in conjunction with search pattern design and implementation units <b>38</b> and <b>40</b> respectively, supports searches to, (1) generate periodic statistical reports, (2) detect claim fraud and abuse, and (3) detect outbreaks of epidemics, caused either by natural disease or by human (terrorist) activity and other searches, for example. Search results may include worklists or reports and search criteria may be stored as rules in rules repository <b>74</b>.

[0033] Interface <b>10</b> provides access by participants <b>30</b> to claim data and rule repositories <b>68</b> and <b>74</b> via portals <b>20</b>-<b>28</b> using a security function <b>12</b>, translator function <b>14</b> and transport function <b>16</b>. Security function <b>12</b> determines whether a participant is authorized to communicate with another particular participant and whether a participant is authorized to access particular data and assigns participant privileges and entitlements and maintains security and access rules. Unit <b>12</b> rejects and tracks unauthorized requests that violate security and other (e.g., HIPAA) policies. Translator function <b>14</b> converts data between the different data formats used by internal and external participants in the FIG. 1 system. For this purpose, translator <b>14</b> converts data from a first data format into an internally defined intermediate data format and from the intermediate format into a desired output data format. Transport function <b>16</b> supports communication of data and messages between internal functions of the FIG. 1 system and between internal functions and external participants. For this purpose function <b>16</b> uses relationship rules repository <b>18</b> to identify required connection protocols and methods as well as source and destination addresses. Function <b>16</b> also uses rules repository <b>18</b> in encoding data in the appropriate message format and protocol and in initiating necessary hand shaking and other routines required to implement bidirectional communication.

[0034] Relationship rules repository <b>18</b> contains information identifying the application programmer interfaces (APIs) used by participant and system software applications and the required procedure for requesting information from particular sources and providing information to particular participants. The participant API identification and related communication information is provided by individual participants for storage in repository <b>18</b>. The participants retain control over and maintain their respective communication support information. Interface <b>10</b> uses the stored predetermined API and communication information in supporting conversion of data from a first data format into an internally defined intermediate data format and from the intermediate format into a desired output data format. As a consequence, participants are able to update their own systems and to communicate with other participants regardless of the rule standards in use or whether the repositories are migrated to new platforms or radically altered in other ways. Also data format standards involved may be changed by an individual participant without impeding operation by other participants.

[0035]FIG. 2 shows a trial adjudication system including server based functions (specifically functions <b>42</b>, <b>46</b>, <b>48</b> and <b>52</b> in server application <b>11</b>) used in the overall claim processing system of FIG. 1. As previously described, collated claim data derived from repository <b>68</b> via unit <b>64</b> is submitted for pre-processing by trial adjudicator <b>48</b> in conjunction with rule execution unit <b>46</b> using rules derived from repository <b>74</b> via unit <b>66</b>. Thereby the trial adjudication system determines expected adjudication results when a specified set of claim data is submitted to a specified payer and validates the collated claim data is in condition for processing to initiate generation of payment. The result of the trial adjudication is accessible by a provider or payer using portals <b>20</b> and <b>22</b> respectively via interface <b>10</b> directed by management rules in repository <b>18</b>. A particular rule result that gives rise to an exception condition invokes operation of exception processing <b>42</b> to schedule manual intervention, via a user interface or a worklist or by communicating a message to a recipient, for example. Further, unit <b>48</b> uses rules in repository <b>74</b> which may include rules derived from external rule sources (such as rules <b>62</b> owned by a payer institution <b>60</b>) by rule accessor <b>52</b> via interface <b>10</b> and data network <b>58</b>, for example.

[0036]FIG. 3 shows a flowchart of a process employed by the system of FIG. 1 in claim processing. In step <b>303</b> acquisition unit <b>32</b> in conjunction with data interface unit <b>64</b> collates data related to a claim of a particular patient for storage in data repository <b>68</b>. FIG. 4 shows a. user interface display image illustrating a claim billing record for a particular patient (the patient is identified by item <b>420</b>). The billing record includes collated claim data for multiple patient encounters <b>402</b>, <b>404</b> and <b>406</b> with a healthcare provider concerning treatment of an injury. FIG. 5 shows a user interface display image <b>500</b> illustrating another format record for the same particular patient (item <b>420</b>) indicating payer related information. In step <b>307</b>, rules acquisition unit <b>54</b> (and <b>52</b>) accumulates rules for storage via interface unit <b>66</b> in repository <b>74</b>. The rules are accumulated from local and remote sources including, payer institutions, messages received from payer institutions, payer institution websites, a rule creation processor used to create rules in response to previously identified claim data deficiencies and regulatory guidelines and directives from governmental and regulatory rule providers. In step <b>309</b>, trial adjudication processor <b>48</b>, in conjunction with rule execution unit <b>46</b> processes collated claim data acquired from repository <b>68</b> to identify a condition triggering application of a first set of rules used for determining validity of an individual claim element of the collated claim data. Units <b>46</b> and <b>48</b> apply a first set of rules in response to detection of a first condition state and a second set of rules in response to detection of a second condition state (both sets of rules being derived from repository <b>74</b>). A condition triggering application of rules may include, for example, (a) generation of a record for incorporation in claim data for a patient, (b) detection of a record addition to claim data for a patient, (c) detection of a record addition to a patient billing record, (d) detection of a change in a patient billing record and (e) detection of a change in claim data for a patient.

[0037] An individual validation rule may contain one or more tests to identify a true condition and initiate an associated first set of actions or a false condition and initiate an associated second set of actions. A rule may detect the absence of an insured persons name as illustrated in the warning item <b>502</b> in the claim record of FIG. 5, for example. Item <b>503</b> further indicates this warning condition triggers holding of the claim and generation of a report. A rule test condition may be simple or complex involving a combination of tests linked with logical operators (e.g., “and,” “or,” “not”). Individual linked tests results are logically combined to provide an overall test true or false result. Further, a set of actions may be an empty set triggering no actions. If no trigger condition is detected a default true condition is declared. Rules repository <b>74</b> (FIG. 1) includes executable rules and the test components incorporated within the individual rules together with an English language description documenting individual rule function for use in help prompts and explanation to nontechnical users and other users. A start and end date and time indicating a period of validity is also maintained by repository <b>74</b> for both a rule and individual test components incorporated by the individual rule. Unit <b>46</b> examines rule validity periods and does not execute a rule or test component at a time and date falling outside of a period of validity.

[0038] In step <b>311</b> (FIG. 3), trial adjudication unit <b>48</b> submits the collated claim data for processing by unit <b>46</b> (FIG. 1) using a set of rules identified in step <b>309</b> (e.g., a first set of claim data validation rules) to validate the collated claim data is in condition for processing to initiate generation of payment. If a remotely located set of rules is identified in step <b>309</b> (e.g., rules maintained by a payer institution), unit <b>48</b> submits the collated claim data for processing with the remotely located rules using a claim data submission procedure (stored in repository <b>74</b>) provided by the rule owning institution. For this purpose unit <b>48</b> employs rule accessor <b>52</b> and network <b>58</b> in accessing the remotely located rules <b>62</b> via payer institution <b>60</b>, for example. An individual validation rule comprises a procedure for determining claim elements comply with predetermined requirements such as, health plan reimbursement conditions, health plan claim format requirements, a reimbursement formula, reimbursement constraints or a reimbursement computation procedure, for example. An exemplary rule detects inconsistency between data fields such as data fields retaining a telephone number, zip code, address or other geographical identifier of the collated claim data. Alternatively, a rule may determine whether an element of the collated claim data exceeds a payer designated limit, for example. Further, an individual claim element processed by a rule may comprise, a portion of a claim, a complete claim, individual records of a claim or record data associated with an individual patient encounter with a healthcare service provider, for example.

[0039]FIG. 7 shows exemplary rules and associated corresponding error codes (in the left column) identifying any errors resulting from application of the rules to patient claim data. The rules are categorized and comprise a first set of rules (rules <b>703</b>-<b>707</b> in category <b>2</b> in FIG. 7 right column) for determining validity of an individual claim element and a second set of rules (rules <b>700</b>, <b>709</b>, <b>717</b>-<b>721</b> in category <b>1</b> in FIG. 7 right column) for use in processing collated claim data for a completed claim. Some rules (rules <b>711</b>-<b>715</b>) reside in both categories. Rules <b>703</b> and <b>705</b>, detect and generate a warning if a date of a service provided to a patient conflicts with prescribed reimbursement date ranges and rule <b>707</b> detects and generates a warning if a particular procedure code is not covered by a particular payer plan, for example. Similarly, rule <b>709</b> identifies and generates a warning for an invalid patient admission date and rule <b>717</b> identifies and generates a warning if an occurrence (e.g., an injury) date falls after an admission date. Rules <b>711</b>, <b>713</b> and <b>715</b> detect and generate a warning if a diagnosis code, procedure code or a combined code of a service provided to a patient, conflicts with the recorded age or gender of the patient concerned. Rule <b>700</b> detects and generates a warning if a claim contains a cause of injury but no place of injury. Rule <b>719</b> detects and warns of invalid inpatient revenue codes and rule <b>721</b> detects and warns of improperly combined charges in this case mammogram charges are to be separately billed, for example. Unit <b>48</b> (FIG. 1) in conjunction with unit <b>46</b> automatically corrects deficiencies identified by the rules in repository <b>74</b> (e.g., the rules of FIG. 7) using claim data information in repository <b>68</b> to resolve inconsistencies or to add missing data. If a condition is detected that is not automatically resolvable human intervention and review is scheduled as previously described.

[0040]FIG. 6 shows a user interface display image illustrating claim pre-processing results of applying validation rules in step <b>311</b> (FIG. 3) and identifying claim rejection reasons by description and rejection code. Specifically, line <b>600</b> indicates error list heading labels defining columns comprising, an error code sequence, an error code identifier and level, an error code sub-identifier, error description text and cleared errors identifying errors that have been corrected (none in this example). Lines <b>602</b>-<b>617</b> list results of applying validation rules in step <b>311</b> to claim data for a patient. The results list identifies <b>7</b> claim rejection reasons comprising, an invalid revenue code (<b>602</b>), a data format deficiency (<b>607</b>), a missing name portion (<b>609</b>), an accommodation data omission (<b>611</b>), a revenue code related error (<b>613</b>), a procedure code related error (<b>615</b>) and accommodation or ancillary data omission (<b>617</b>).

[0041] In step <b>315</b> of FIG. 3, in response to unsuccessful claim validation in step <b>311</b>, trial adjudication unit <b>48</b> in conjunction with unit <b>46</b>, applies rules for use in editing the collated claim data. Specifically, units <b>48</b> and <b>46</b> automatically edit the collated claim data to correct an identified deficiency likely to result in claim denial. Units <b>48</b> and <b>46</b> also initiate functions involving manual data review or manual intervention in the claim data correction process. Such functions include, for example, scheduling a task to be performed by a healthcare worker (such as to correct a deficiency in the collated claim data), creating an error report for review, creating a record of a result of applying the claim data editing rules (for use in future claim data editing), generating an alert message to a user to indicate that a deficiency in the collated claim data is likely to result in claim denial, creating an accounting report, generating a claim and initiating sending of a remittance. Other functions include, initiating pattern searches and other statistical analyses of claim and other data, maintaining logs of activities, adding items to reports, and categorizing sets of data (to indicate for instance, one claim is error-free, but that another claim is on a particular worklist for correction). In step <b>317</b>, following automatic or manual editing of the collated claim data to provide amended claim data, unit <b>48</b> automatically queues the amended collated claim data for re-validation by unit <b>48</b> in conjunction with unit <b>46</b>.

[0042] In step <b>321</b>, trial adjudication unit <b>48</b> in conjunction with unit <b>46</b>, resubmits the claim data (amended in step <b>315</b>) for processing using the validation rules. This is done to re-validate whether the amended claim data is in condition for processing to initiate generation of payment. In response to successful claim data revalidation in step <b>321</b> or successful validation in step <b>311</b>, unit <b>48</b> employs interface <b>10</b> and network <b>58</b> in step <b>323</b> to submit the validated claim data to a payer to initiate payment. For this purpose interface <b>10</b> uses relationship repository <b>18</b> to process the validated claim data to provide the data format, protocol, handshaking routine and submission procedure predetermined (and retained and identified in repository <b>18</b>) by the payer. In response to receiving the validated claim data, a payer accepts and adjudicates the validated claim data and records issuance of a remittance to the claimant healthcare provider and patient (if applicable). A healthcare provider also generates an additional secondary claim to a secondary provider in the case that a claim is partially covered by a primary payer and another claim portion is covered by a secondary payer. The secondary claim trial adjudication and submission procedure similarly follows the process of FIG. 3 for a primary claim.

[0043] In response to an unsuccessful re-validation in step <b>321</b>, unit <b>48</b> initiates scheduling of manual review of the claim data. In an alternative embodiment, the FIG. 3 process may be repeated starting at step <b>315</b> for a predetermined number of iterations prior to declaring failure and initiating manual claim review. Upon completion of processing of validated claim data, the claim data is archived in data warehouse <b>72</b> via historian unit <b>70</b>. In step <b>327</b>, unit <b>48</b> employs interface <b>10</b> to support claim data access and exchange of data between the system and external entities such as a patient, a payer, a healthcare provider, an employer of a patient and a governmental agency. The accessed data is displayed to a user via a generated user interface image on portals <b>20</b>-<b>28</b>, for example. For this purpose interface <b>10</b> uses relationship repository <b>18</b> to process the accessed claim data to provide the claim data in the predetermined data format and communication protocol desired by the requesting external or internal entity. Similarly, interface <b>10</b> uses relationship repository <b>18</b> to process the accessed claim data to implement the predetermined handshaking routine and submission procedure desired by the requesting entity.

[0044] In step <b>329</b>, following successful validation of multiple sets of collated claim data verifying the system operates in accordance with particular payer rules, a system certification is obtained from the particular payer. This certification signifies a threshold level of capability of the FIG. 1 system has been achieved. The process detailed in the flowchart of FIG. 3 ends at step <b>331</b>.

[0045] The systems, processes and user interface display formats presented in FIGS. <b>1</b>-<b>14</b> are not exclusive. Other systems, processes and user interface forms may be derived in accordance with the principles of the invention to accomplish the same objectives. The inventive principles are applicable to streamlining and automating a revenue management process in any industry or field. The principles are particularly applicable to the insurance, government and healthcare industries.