Automated Insurance Claim Processing with Explanation Code Hierarchy
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Solution Overview
Problem
Insurance claim workflows are lengthy and prone to errors due to conflicts in explanation codes, requiring manual correction by analysts, which can lead to flawed claims and increased processing time.
Innovation Solution
A computer-based system that processes insurance claims by determining hierarchical ranks for explanation codes, modifying lines based on these ranks, and ordering codes for user review and adjustment, thereby reducing conflicts and automating the claims workflow.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Measurement precision
If manual review and correction of explanation codes is performed, then accuracy of claim processing is improved, but processing time increases and productivity decreases
Solution Approach 1:
The system performs self-service by automatically determining hierarchical ranks of explanation codes and modifying claim lines without requiring manual intervention. The automated logic rules resolve conflicts between explanation codes independently, eliminating the need for analysts to manually review and correct each conflict, thus maintaining accuracy while significantly improving processing speed.
Solution Approach 2:
The patent replaces the mechanical manual review process with an automated computer-based system. The system uses algorithms to determine hierarchical ranks, apply logic rules to resolve conflicts, and modify claim lines automatically. This substitution of mechanical manual operations with automated electronic processing eliminates time-consuming manual tasks while preserving processing accuracy.
2Device complexity
If explanation codes are processed without hierarchical ranking, then processing simplicity is maintained, but conflicts between codes increase and reliability decreases
Solution Approach 1:
The system performs preliminary action by pre-establishing hierarchical ranks for different types of explanation codes before processing claims. The database stores predefined hierarchy levels (e.g., billing rules, contract terms, policy provisions) that are applied automatically during claim processing. This preliminary organization of coding structures prevents conflicts before they arise and ensures consistent, reliable payment decisions without adding complexity to the actual claim processing workflow.
Solution Approach 2:
The patent changes the parameter of explanation code processing by introducing hierarchical ranking dimensions. Instead of treating all explanation codes equally, the system assigns different weights and priorities based on their hierarchical level. This parameter change enables the system to automatically resolve conflicts by applying higher-ranked codes over lower-ranked ones, thereby improving reliability while maintaining processing simplicity through automated application of the hierarchy.
3Productivity
If automated processing is implemented without hierarchical structure, then processing speed increases, but errors in code prioritization occur and measurement precision decreases
Solution Approach 1:
The system incorporates feedback mechanisms where the automated processing results are reviewed and validated. The database of explanation code ranks provides feedback loops that allow the system to learn from previous processing outcomes and adjust its prioritization logic. This feedback ensures that automated processing maintains high measurement precision by continuously validating code prioritization decisions while preserving the speed benefits of automation.
Data Source
AI summary
In some embodiments, a computer-implemented method comprises: storing associations between explanation codes and hierarchical ranks in a database; receiving a first electronic document representing an insurance claim comprising a line comprising a procedure code and at least two explanation codes; determining hierarchical ranks for the explanation codes by at least one of: applying the explanation codes to the database, and executing rules selected according to the explanation codes; determining, according to the determined hierarchical ranks, whether the line should be modified; modifying the line; ordering the explanation codes according to the hierarchical ranks; providing a user interface displaying the modified line with the ordered explanation codes and user-operable controls; adjusting the line responsive to user operation of the user-operable controls; and outputting a second electronic document representing the insurance claim after adjusting the line.