System and method for real-time healthcare claim adjustment

A method for automated healthcare claims adjustment in real-time, wherein the method is implemented by a processor executing program instructions stored in a memory, the method comprises:

• transmitting a pre-authorization request associated with the healthcare claims adjustment based on a first set of rules, wherein one or more requirements associated with the pre-authorization requests are verified using a pre-authorization checking Application Programing Interface (API);
• determining a need for authorization for the pre-authorization request based on a second set of rules, wherein the need for authorization for the pre-authorization request is determined as a first action response;
• performing a second action response based on a third set of rules, subsequent to the first action response, for determining whether the healthcare claims adjustment request is pending for review;
• and
• populating a pre-defined servicing field with data associated with the first user type for performing healthcare claims adjustment, wherein external devices are triggered to execute actions associated with healthcare claims adjustment based on the populated data.

A computer program product comprising:

• a non-transitory computer-readable medium having computer program code stored thereon, the computer-readable program code comprising instructions that, when executed by a processor, causes the processor to:
• transmit a pre-authorization request associated with the healthcare claims adjustment based on a first set of rules, wherein one or more requirements associated with the pre-authorization requests are verified using a pre-authorization checking Application Programing Interface (API);
• determine a need for authorization for the pre-authorization request based on a second set of rules, wherein the need for authorization for the pre-authorization request is determined as a first action response;
• perform a second action response based on a third set of rules, subsequent to the first action response, for determining whether the healthcare claims adjustment request is pending for review;
• and
• populate a pre-defined servicing field with data associated with the first user type for performing healthcare claims adjustment, wherein external devices are triggered to execute actions associated with healthcare claims adjustment based on the populated data.