Adaptive system for financial claim reimbursement processing

摘要

A system improves payment claims transactions by analyzing payments transactions to update payment edit rules according to information derived from the transactions. A system adapts rules used for processing claim adjudication data provided by a payer organization concerning a claim for reimbursement for provision of healthcare to a patient previously submitted to the payer organization in a claim. The system includes a data processor for parsing claim adjudication data provided by a specific payer organization in an electronic transaction message to identify data comprising, (a) a payer organization identifier and (b) a reason for rejection of a claim. A rules processor automatically generates a payer specific rule for use in pre-processing a claim for submission to the specific payer identified by the payer organization identifier by translating data comprising the reason for rejection into a logical expression resolvable using data elements in a claim. A rules repository accumulates data representing automatically generated payer specific rules for pre-processing a claim for submission to the specific payer.