Eligibility Response Normalization and Alert Embedding
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Solution Overview
Problem
Current healthcare systems face challenges in properly documenting and consistently communicating insurance eligibility and benefit information, leading to time-consuming and error-prone processes for healthcare providers, due to improper or inconsistent data in 271 responses.
Innovation Solution
A system that normalizes codified data in eligibility responses and proactively identifies issues by mapping patient and payer data, embedding alerts with instructions for rectification, and standardizing terminology, thereby providing a consistently formatted and user-friendly response.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Measurement precision
If manual verification methods (cheat sheets) are used to check eligibility data, then users can identify information needed for registration, but the process becomes very time-consuming and error-prone
Solution Approach 1:
The patent replaces manual mechanical verification processes (users reviewing cheat sheets and comparing data elements) with an automated computer-based system that retrieves eligibility data, compares it against required fields, and generates alerts for missing or inconsistent information. This substitution eliminates manual time consumption while maintaining verification accuracy.
Solution Approach 2:
The system performs self-verification by automatically retrieving eligibility data from payers, comparing it with registration requirements, and identifying issues without human intervention. The automated alerts enable the system to self-diagnose data quality problems, reducing reliance on manual review processes.
2Reliability
If manual verification processes are implemented to ensure data consistency, then data accuracy can be maintained, but the complexity of the system increases
Solution Approach 1:
The patent introduces an intermediary automated verification system that acts as a bridge between raw eligibility data and registration processes. This intermediary automatically retrieves data, performs consistency checks against predefined requirements, and generates standardized alerts, thereby maintaining reliability without requiring complex manual verification procedures.
3Productivity
If eligibility data is retrieved and processed without normalization, then the raw information can be obtained, but the information may be improperly documented or inconsistent with patient information
Solution Approach 1:
The patent applies preliminary normalization and validation actions to eligibility data immediately upon retrieval. The system compares incoming data against predefined registration requirements before the data is used, identifying and alerting users to documentation issues in advance, thereby ensuring quality without slowing down the overall retrieval process.
Data Source
AI summary
Normalizing codified data in an eligibility response and proactively identifying insurance eligibility and benefit documentation issues is provided. Data in an eligibility response may be mapped with other data including data received from healthcare providers, payers, data from inquiries, etc. The data may be stored in tables, and/or in internal and external databases. If there are any determined issues discovered, an alert of the issue found is embedded in the response or the determined issue may be automatically corrected. The alert may provide an instruction on how to rectify the issue to a healthcare provider administrative user. The formatting and structure of the eligibility response may be normalized such that message segments relating to a same service type are grouped together, providing a consistently formatted normalized response. Accordingly, an end user may be able to more easily find information in the normalized eligibility response.