Systems and methods for recovery audit scope determination

A computer-based method for determining required data elements for a recovery audit based on identified claim types, comprising:

• providing a database including claim types and data elements, wherein relationships between the claim types and data elements are defined;
• providing a list of claim types to a user;
• receiving input identifying at least two claim types desired for a recovery audit;
• determining what data elements are required to write the identified at least two claim types;
• receiving input identifying a number of allowable missing data elements for identifying potential claims not identified by the user;
• determining what additional claim types require a number of missing data elements equal to or less than the number received;
• and
• presenting the additional claim types to the user.

A computer-based system that determines claim types that can be written in a recovery audit, comprising:

• a database including claim types and data elements, wherein relationships between the claim types and data elements are defined;
• a scope determination module that determines claim types that can be written based upon data fields identified by a user and the relationships between the claim types and data elements;
• a web server that sends the potential claims to a remote computing device;
• wherein the scope determination module receives input identifying a number of allowable missing data elements and determines what additional claim types require a number of missing data elements equal to or less than the number received;
• and
• sends a list of the additional claim types to a user device that presents the additional claim types to the user.