US 2017/0286606 A1Published application

Apparatuses, methods, and computer program products for customized pricing of claims for reimbursement

AssigneeChange Healthcare LLC

InventorsMarc Lassin, Michael Prissovsky, Richard Fritzson, Debra Franklin, David Russell

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Abstract

Apparatuses, methods, and computer program products are provided for pricing claims for reimbursement within a claim pricing software application presented in a graphical user interface. In particular, a software application is described in which a processing logic for processing claims is visible to the user, and the user is able to interact with and manipulate various parts of the processing logic to develop customized payment methodologies that reflect payor-provider contractual relationships and negotiated terms for reimbursement. Accordingly, input is received from the user via input fields of the graphical user interface that define a payment methodology of the claims for reimbursement, where the input comprises selection of predefined code portions (including variables and functions) to define a customized payment methodology for pricing the claim.

Claims20

Dependent claims

A pricing engine core comprising at least one non-transitory computer-readable storage medium having computer-executable program code portions stored therein, the computer-executable program code portions comprising program code instructions for:

receiving claim data comprising details of a claim for reimbursement;
accessing a rate schedule, wherein the rate schedule comprises a codified representation of financial terms from a contract used to price the claim, wherein the rate schedule includes product data for one or more products;
receiving selection of a product;
and
determining pricing of the claim for reimbursement based on the rate schedule accessed and the product selected, wherein determining pricing of the claim comprises:
accessing the product data of the rate schedule,
executing a list of active service categories based on the product data accessed from the rate schedule, wherein each service category specifies one or more service category criteria,
determining the service category of the claim by comparing each service category criteria of a respective service category to the claim data, wherein the service category determined further comprises one or more service groups and wherein each service group comprises service group criteria,
executing the service group criteria for at least one of the service groups of the service category determined against the claim data to select an appropriate service group for the claim,
determining a list of payment methodologies from the service group selected for the claim, and
executing at least one of the payment methodologies determined to price the claim for reimbursement.

8 more elements

A computer-implemented method for pricing claims for reimbursement within a claim pricing software application presented in a graphical user interface, the method comprising:

providing for display of a first screen comprising an input field within a graphical user interface;
receiving input from a user via the input field of the first screen comprising data identifying a rate schedule to be used for pricing a claim;
receiving a selection from the user of a product;
receiving a selection from the user of a service category of the claim;
providing for display of a second screen comprising an input field within the graphical user interface, wherein the input field of the second screen is configured to receive input from the user of criteria to be associated with the selected service category;
receiving selection from the user of a service group for the selected service category;
providing for display of a third screen comprising an input field within the graphical user interface based on the service group selected;
and
receiving input from the user via the input field of the third screen defining a payment methodology of the claims, wherein the input from the user comprises selection of predefined code portions to define a customized payment methodology for pricing the claim.

6 more elements

An apparatus for pricing claims for reimbursement within a claim pricing software application presented in a graphical user interface, the apparatus comprising at least one processor and at least one memory including computer program code, the at least one memory and the computer program code configured to, with the processor, cause the apparatus to at least:

provide for display of a first screen comprising an input field within a graphical user interface;
receive input from a user via the input field of the first screen comprising data identifying a rate schedule to be used for pricing a claim;
receive a selection from the user of a product;
receive a selection from the user of a service category of the claim;
provide for display of a second screen comprising an input field within the graphical user interface, wherein the input field of the second screen is configured to receive input from the user of criteria to be associated with the selected service category;
receive selection from the user of a service group for the selected service category;
provide for display of a third screen comprising an input field within the graphical user interface based on the service group selected;
and
receive input from the user via the input field of the third screen defining a payment methodology of the claims, wherein the input from the user comprises selection of predefined code portions to define a customized payment methodology for pricing the claim.

6 more elements

Dependencies are inferred from the claim text.

Facts

Application: 15/458,583Filed 14 Mar 2017
Priority: 31 Mar 2016
Published: 5 Oct 2017
Term ends: Not estimatedThe source records don’t support an estimate.

Classification4 codes

G16H 40/63
For the operation of medical equipment or devices: for local operation
G06Q 10/10
Administration; Management: office automation; Time management
G16H
Healthcare informatics, i.e. information and communication technology [ict] specially adapted for the
G06Q
Information and communication technology [ict] specially adapted for administrative, commercial, financial, managerial

Family

Application62/316,296Us provisional application · filed 31 Mar 2016
US 2017/0286606 A1This patent

From the US filing history. Foreign family members aren’t listed.

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