Method and system for adjudicating claims in a health services environment

A method for determining the appropriateness of service provider claims for payment, in a computer system, comprising:

• scheduling appointments, in the computer system, with service providers;
• receiving claims, in the computer system, from the service providers;
• determining, in the computer system, whether at least one scheduled appointment can be matched with at least one received claim;
• determining, in the computer system, that at least one scheduled appointment has not been identified as corresponding to at least one received claim within a predetermined period of time;
• and
• presenting the particular received claim for payment when at least one of the scheduled appointments corresponds to the particular received claim.

A system for determining the appropriateness of service provider claims for payment, comprising:

• a scheduling module configured to schedule appointments with service providers;
• a claim intake module configured to receive claims from the service providers;
• an adjudication module configured to present at least one received claim for payment upon matching the at least one received claim to a scheduled appointment and present at least one received claim for payment upon matching the at least one received claim to a scheduled appointment;
• and
• a claims acquisition module configured to determine that at least one scheduled appointment has not been identified as corresponding to at least one received claim.