Method and system for processing health care electronic data transactions

A method of filing health care claims electronically when health care services are provided to a patient by a service provider and paid by a third party payor upon the receipt of a medical claim pursuant to a health care insurance policy, said method comprising:

• (a) encoding a health care data card with a machine readable data file, said data file including a two dimensional pattern of marks wherein the encoded marks together include a plurality of information words, including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the payor;
• (b) imprinting the card with human readable indicia and issuing the card to a patient to be carried by the patient for a period as defined by said insurance policy,
• (c) scanning the machine readable data file at a service provider facility and decoding said two dimensional pattern of marks into a plurality of separated patient digital fields and insurer digital fields, each of said fields enabling one or more information words to be decoded therefrom;
• (d) entering a plurality of service provider digital fields at said service provider facility, said service provider digital fields representing at least one service provided to said patient,
• (e) interleaving said separated patient digital fields and said insurer digital fields from said scanning step and said plurality of service provider digital fields from said entering step and assembling said fields electronically to form a health care claim to be presented to said payor for payment thereof on behalf of the patient;
• (f) assembling one or more health care claims for services rendered to one or more patients by said service provider;
• and
• (g) electronically transmitting said health care claim(s) for services rendered to said patients(s) by said service provider to said insurer via a common carrier data communication.

An apparatus for filing health care claims electronically when health care services are provided to a patient by a service provider and paid by a third party payor upon the receipt of a medical claim pursuant to a health care policy, said apparatus comprising:

• (a) a scanner for scanning a machine readable data file encoded on a health care data card carried by the patient, said data file including a two dimensional pattern of marks wherein the encoded marks together include a plurality of information words, including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the third party payor;
• (b) a decoding means for decoding said two dimensional pattern of marks into a plurality of separated patient digital fields and payor digital fields, each of said fields enabling one or more information words to be decoded therefrom;
• (c) data entry means for entering a plurality of service provider digital fields entered by said service provider, said service provider digital fields representing service provided to said patient,
• (d) a data processing means for receiving said separated patient digital fields and said insurer digital fields from said reader, and said plurality of service provider digital fields entered by said service provider, said data processing means assembling said fields to form a health care claim to be presented to said payor for payment thereof on behalf of the patient;
• (e) data memory means for storing one or more health care claims for services rendered to one or more patients by said service provider;
• (f) data communication means for transmitting one or more health care claims from said service provider to said payor via a common carrier.

A system for assembling, filing and processing health care claims made by patients pursuant to coverage policies issued to the patients by claim payors for service provided to the patients at health care facilities, the network comprising:

• a multitude of participating patients, each of the patients having a respective one portable personal data file including a set of patient related data including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the payor and encoded in a machine readable format;
• a multitude of health care facilities, for providing health care services to the participating patients, each of the health care facilities having
• i) a telecommunications unit, and
• ii) a file reader to read the data on the personal data files and to transmit the patient related data to the telecommunications unit at the facility, wherein the telecommunications unit includes a control program having (1) a series of prompts, and (2) a claim assembling program to present the prompts in a human understandable format to solicit from an operator data related to services provided to the patients at the health care facility, and to assemble the patient related data from the personal data files and the service related data from the operator into electronic claim forms;
• a plurality of claim payor companies having telecommunications units;
• a central clearinghouse connected to the telecommunications units of the health care facilities and connected to the telecommunications units of the claim payor companies, the claims processing unit including
• means to receive the electronic claim forms from the health care facilities, to check the electronic claim forms and to transmit said claims to the payor companies for adjudication and payment.

A computer system for electronically assembling a health insurance claim, each of said claims including patient related data and treatment related data, the system comprising:

• a data processing unit;
• a memory unit including a claim assembly area;
• means connecting the clearinghouse unit and the memory unit together to transmit data therebetween;
• input means for receiving data, and including
• i) means to receive patient related data including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the payor in an electronic format, and
• ii) means to receive input from an operator;
• output means for transmitting data from the computer system, and including a screen;
• and
• a control program stored in the data processing unit, and including
• i) a series of prompts, and
• ii) a claim assembling program to present the prompts on the screen in a predefined order to prompt the operator to input the treatment related data, and to transmit the patient related data and the treatment related data to the claim assembly area to assemble an electronic claim form therein.

A computer program for electronically assembling health care claims in a computer system, wherein each of the health care claims includes patient related data and treatment related data, and wherein the program is for use with a computer system including a data processing unit, a memory unit, first input means to receive patient related data in an electronic format, second input means to receive input from an operator, and a screen, the computer program comprising:

• a carrier medium;
• and
• a control program stored on the carrier medium, and including
• i) a series of prompts, and
• ii) a claim assembling program for operating the computer system to present the prompts on the video monitor in a predefined order to prompt the operator to input the treatment related data, and to transmit the patient related data including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the payor and the treatment related data to the memory area of the computer system to assemble an electronic claim form in said memory area.

A system for processing insurance claims for services received by patients, the system comprising:

• a portable personal data file including a set of data related to a patient including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the payor and encoded in a machine readable format;
• a local telecommunications unit including
• i) input means for receiving input data from an operator,
• ii) output means,
• iii) a memory unit,
• iv) a control program, and
• v) a series of prompts stored in the memory area for soliciting input data from the operator related to services received by the patient;
• and
• a reader for reading the patient related data from the portable personal data file and transmitting said patient related data to the processing unit;
• wherein the control program operates (i) to present the prompts on the output means in a human understandable format and in an order determined in accordance with a preset program, to solicit from the operator the treatment related data, and (ii) to assemble the patient related data received from the reader and the treatment related data received from the operator, in the memory area to form an electronic claim form therein.

A method for processing insurance claims for services received by patients, the method comprising:

• providing a two-dimensional portable personal data file including a set of data related to a patient including patient identification, third party payor identification, and entitlement and benefit information relation to the relationship between the patient and the payor and encoded in a machine readable format;
• providing a local telecommunications unit including a memory section;
• using a machine to read the patient related data from the portable personal data file and to transmit said patient related data to the telecommunications unit;
• presenting a series of prompts to an operator, in an order determined in accordance with a preset program, to solicit from the operator input data related to services received by the patient;
• responding to the prompts by inputting to the telecommunications unit the service related data;
• and
• assembling the patient related data and the treatment related data in the memory section of the telecommunications unit to form an electronic claim form therein.