Claims Processing Interface Scripting for Adjudication Efficiency
Find Innovative SolutionsGenerate Solutions
Solution Overview
Problem
Manual insurance claim adjudication processes become overloaded due to increasing claims, requiring claims processors to navigate multiple computer screens, leading to inefficiencies and potential errors.
Innovation Solution
A system and method that provide a graphical user interface guiding claims processors through the adjudication process using scripting processes based on required claim edits and common scenarios, reducing keystrokes and routing claims to users based on skill level and claim type.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If manual claims adjudication processes are used, then flexibility in handling diverse claims is maintained, but processor productivity decreases due to navigating multiple screens and manual data entry
Solution Approach 1:
The patent consolidates multiple computer screens and data sources into a single integrated graphical user interface that displays all necessary claim information, edits, and processing tools in one view. This merging eliminates the need for processors to navigate between multiple screens while maintaining access to all required data and functions.
Solution Approach 2:
The patent introduces a scripting process as an intermediary between the claims processor and the complex claims data. This scripting layer automatically retrieves, organizes, and presents relevant information in a standardized format, reducing the cognitive load and manual effort required to process diverse claims while maintaining flexibility.
2Reliability
If standardized scripting processes are implemented, then processing consistency and compliance improve, but adaptability to unique claim scenarios may be reduced
Solution Approach 1:
The scripting process is designed to be dynamic rather than rigid. It automatically adapts its behavior based on the specific claim data, edit requirements, and processing scenario encountered. The script can adjust its workflow, data retrieval queries, and presentation format dynamically to suit each unique claim while maintaining standardized processing steps.
Solution Approach 2:
The system changes parameters of the scripting process based on the specific claim being processed. Different claims trigger different script configurations, data sources, and processing rules, allowing the same basic scripting framework to handle diverse scenarios with appropriate parameter adjustments rather than requiring completely different processing approaches.
3Productivity
If claims are routed based on user skill level and claim characteristics, then processing efficiency improves, but system complexity increases due to routing logic
Solution Approach 1:
The system performs preliminary analysis of claims and user profiles before routing occurs. Claim characteristics, complexity metrics, and user skill levels are pre-evaluated and stored, allowing the routing logic to make quick matching decisions without complex real-time analysis. This preliminary preparation simplifies the actual routing decision process.
Solution Approach 2:
The routing system uses profiling and matching rather than complex custom logic for each routing decision. User skill profiles and claim type profiles are created as templates, and routing is achieved by matching claims to the most appropriate user profile copy, reducing the need for complex conditional routing logic while maintaining efficiency.
Data Source
AI summary
A system for providing a claims processing environment for facilitating claim adjudication includes a processor for generating an electronic interface configured to enable a user to edit claim data requiring one or more edits and for receiving the one or more edits, and a data storage component for storing the claim data and the received one or more edits, where the processor provides a scripting process based on the required one or more edits for facilitating user entry of the required one or more edits, said scripting process associated with the electronic interface. A method for facilitating claim adjudication includes identifying one or more claim edits required in a set of claim data for the claim data to adjudicate, providing a scripting process based on the required one or more claim edits, said scripting process facilitating entry of the required one or more claim edits, and receiving and validating the received claim edits.