Electronic creation, submission, adjudication, and payment of health insurance claims

Abstract

A claims processing system for electronically reviewing and adjudicating medical insurance claims. The claims processing systems include a benefits system, an automated adjudication system, a payment system, and a payment tracking system. The benefits system allows patients and health care providers to access patient and benefits information on-line. Using the automated adjudication system, health care providers may electronically prepare and submit claims for payment. Before a claim is submitted, a claims precheck process is used to determine whether the claim may be automatically adjudicated or instead must be manually adjudicated. If manual adjudication is indicated, the health care provider may the claim in an effort to achieve automated adjudication prior to claim submission. The claims processing system performs automatic adjudication on submitted claims or forwards the claims to a shop for manual adjudication. The payment system initiates payment to the health care provider using electronic funds transfer. The payment tracking system allows health care providers to monitor the payment status of a claim after submission.