Method and system for adjudicating claims in a health service environment

Abstract

Methods and systems for adjudicating claims in health services environments are presented. An exemplary method for processing service provider claims for payment includes receiving a claim for payment, automatically identifying candidate appointments from a plurality of scheduled appointments based on a degree of similarity between service information associated with the received claim and appointment information associated with the scheduled appointments, analyzing the candidate appointments to determine whether to flag the received claim for resolution, and presenting the received claim for payment when at least one of the candidate appointments corresponds to the received claim. Optionally, the method includes automatically identifying already processed claims based on a degree of similarity between service information associated with the already processed claims and the service information associated with the received claim, analyzing the identified already processed claims to determine whether the received claim is a duplicate claim, and flagging potentially duplicate claims for resolution.