Computerized settlement and invoice validation system for healthcare services

摘要

A computerized settlement and invoice validation application that enables a payor to validate the charges from a healthcare services provider and to better manage contracting and performance management functions. The application supports claims adjudication and payment processing. It validates all patient activity data that is received from healthcare services providers. Patient activity data relates to episodes involving a single patient care event. The application applies to episodes rules related to clinical and financial requirements for the payor. The application tracks details related to application of the rules to episodes and identifies reasons that an episode fails. Episodes that fail are routed to appropriate staff for review and action. Following review, an episode may be accepted for payment or challenged for various reasons. The application automates a variety of manual tasks and limits manual review to only those activities that require further attention and action.