U.S. patent application number 14/049733 was filed with the patent office on 2014-09-04 for interactive electronic bill payment system.
This patent application is currently assigned to Emergis Inc.. The applicant listed for this patent is Emergis Inc.. Invention is credited to Ilan Grosman, David Johnston, Bob Ransom, Mike Schmidt.
Application Number | 20140249975 14/049733 |
Document ID | / |
Family ID | 34865424 |
Filed Date | 2014-09-04 |
United States Patent
Application |
20140249975 |
Kind Code |
A1 |
Schmidt; Mike ; et
al. |
September 4, 2014 |
INTERACTIVE ELECTRONIC BILL PAYMENT SYSTEM
Abstract
A system for coordinating the submission and processing of a
bill according to predictive payment data of a plan. The system
comprises a provider interface and an integrated database for
receiving a predictive payment plan submitted from the provider
interface. The system also has a predictive payment request of the
plan storable in the database, the request including a plurality of
predictive payment parameters. An adjudication engine is coupled to
the integrated database, and an insertion function is used for
inserting the predictive payment parameters, when stored in the
database, into an adjudication rule set of the adjudication engine.
The adjudication rule set is used for eventual adjudication of the
predictive payment data, wherein adjudication of the predictive
payment data results in the generation of the bill. The system also
has a workflow engine coupled to the integrated database for
coordinating the processing of the electronic bill and for updating
the bill information in response to the bill processing. A
management system is coupled to the integrated database for
monitoring the contents of the integrated database accessible by
the provider interface, wherein the provider can coordinate
real-time retrieval of submission and status details for bill
information contained in the integrated database.
Inventors: |
Schmidt; Mike; (Etobicoke,
CA) ; Grosman; Ilan; (Thornhill, CA) ;
Johnston; David; (Toronto, CA) ; Ransom; Bob;
(Bolton, CA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Emergis Inc. |
Longueuil |
|
CA |
|
|
Assignee: |
Emergis Inc.
Longueuil
CA
|
Family ID: |
34865424 |
Appl. No.: |
14/049733 |
Filed: |
October 9, 2013 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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11797316 |
May 2, 2007 |
8645168 |
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14049733 |
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10960984 |
Oct 12, 2004 |
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11797316 |
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10656265 |
Sep 8, 2003 |
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10960984 |
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10277205 |
Oct 22, 2002 |
8108274 |
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10656265 |
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60408884 |
Sep 9, 2002 |
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Current U.S.
Class: |
705/34 |
Current CPC
Class: |
G06Q 40/08 20130101;
G06Q 20/102 20130101; G06Q 30/04 20130101; G06Q 40/02 20130101 |
Class at
Publication: |
705/34 |
International
Class: |
G06Q 30/04 20060101
G06Q030/04 |
Claims
1. An electronic bill processing system for coordinating the
submission and processing of an electronic bill corresponding to a
provider of insurance services, the system comprising: a) a
provider interface; b) an integrated database coupled to the
provider interface for storing bill information pertaining to the
electronic bill; c) a workflow engine coupled to the integrated
database for coordinating the processing of the electronic bill and
for updating the bill information in response to the bill
processing; and d) a management system coupled to the integrated
database for monitoring the contents of the integrated database
accessible by the provider interface; wherein the provider can
coordinate real-time retrieval of submission and status details for
bill information contained in the integrated database.
2. The system according to claim 1 further comprising a search
function for accessing the integrated database through the provider
interface, the search function having a number of search options
for retrieving the bill information.
3. A method for coordinating the submission and processing of a
bill according to predictive payment data of a plan, the method
comprising the steps of: a) storing the predictive payment data
corresponding to the plan in a database coupled to an adjudication
engine; b) inserting a predictive payment parameter into a rule set
of the adjudication engine for eventual adjudication of the
predictive payment data at a predefined interval, the predictive
payment parameter corresponding to a content of the plan; c)
triggering a creation of the electronic bill at the predefined
interval according to the predictive payment parameter; d)
retrieving the predictive payment data from the database and
providing the predictive payment data to the adjudication engine;
and e) updating the predictive payment parameter for recognizing
the submission of the payment data to the adjudication engine; and
f) generating the bill as defined by the predictive payment data of
the plan once adjudicated.
4. The method according to claim 3, wherein a plurality of service
codes is included with the predictive payment parameter.
5. A system for coordinating the submission and processing of a
bill according to predictive payment data of a plan, the system
comprising: a) A PROVIDER INTERFACE; b) an integrated database for
receiving a predictive payment plan submitted from the provider
interface; c) a predictive payment request of the plan storable in
the database, the request including a plurality of predictive
payment parameters; d) an adjudication engine coupled to the
integrated database; and e) an insertion function for inserting the
predictive payment parameters, when stored in the database, into an
adjudication rule set of the adjudication engine, the adjudication
rule set for eventual adjudication of the predictive payment data;
wherein adjudication of the predictive payment data results in the
generation of the bill.
Description
CROSS REFERENCE TO RELATED APPLICATIONS
[0001] This application is a continuation of U.S. patent
application Ser. No. 11/797,316 filed May 2, 2007, which is a
continuation of U.S. patent application Ser. No. 10/960,984 filed
Oct. 12, 2004, which is a continuation of U.S. patent application
Ser. No. 10/656, 265 filed Sep. 8, 2003, which is a continuation in
part of U.S. patent application Ser. No. 10/277,205 filed Oct. 22,
2002, which claims the benefit of U.S. Provisional Patent
Application No. 60/408,884 filed Sep. 9, 2002, all of which are
herein incorporated by reference.
BACKGROUND OF THE INVENTION
Field of the Invention
[0002] The present invention relates to electronic bill submission
and processing, and in particular to insurance claims corresponding
to providers of insurance services.
SUMMARY OF THE INVENTION
[0003] According to the present invention there is provided an
electronic bill processing system for coordinating the submission
and processing of an electronic bill corresponding to a provider of
insurance services, the system comprising; [0004] a) a provider
interface; [0005] b) an integrated database coupled to the provider
interface for storing bill information pertaining to the electronic
bill; [0006] c) a workflow engine coupled to the integrated
database for coordinating the processing of the electronic bill and
for updating the bill information in response to the bill
processing; and [0007] d) a management system coupled to the
integrated database for monitoring the contents of the integrated
database accessible by the provider interface; wherein the provider
can coordinate real-time retrieval of submission and status details
for bill information contained in the integrated database.
[0008] According to a further aspect of the present invention there
is provided a method for coordinating the submission and processing
of a bill according to predictive payment data of a plan. The
method comprises the steps of: [0009] a) storing the predictive
payment data corresponding to the plan in a database coupled to an
adjudication engine; [0010] b) inserting a predictive payment
parameter into a rule set of the adjudication engine for eventual
adjudication of the predictive payment data at a predefined
interval, the predictive payment parameter corresponding to a
content of the plan; [0011] c) triggering a creation of the
electronic bill at the predefined interval according to the
predictive payment parameter; [0012] d) retrieving the predictive
payment data from the database and providing the predictive payment
data to the adjudication engine; [0013] e) updating the predictive
payment parameter for recognizing the submission of the payment
data to the adjudication engine; and [0014] f) generating the bill
as defined by the predictive payment data of the plan once
adjudicated.
[0015] According to a still further aspect of the present invention
there is provided a system for coordinating the submission and
processing of a bill according to predictive payment data of a
plan. The system comprises: [0016] a) a provider interface; [0017]
b) an integrated database for receiving a predictive payment plan
submitted from the provider interface; [0018] c) a predictive
payment request of the plan storable in the database, the request
including a plurality of predictive payment parameters; [0019] d)
an adjudication engine coupled to the integrated database; and
[0020] e) an insertion function for inserting the predictive
payment parameters, when stored in the database, into an
adjudication rule set of the adjudication engine, the adjudication
rule set for eventual adjudication of the predictive payment data;
wherein adjudication of the predictive payment data results in the
generation of the bill.
BRIEF DESCRIPTION OF THE DRAWINGS
[0021] These and other features of the preferred embodiments of the
invention will become more apparent in the following detailed
description in which reference is made to the appended drawings
wherein:
[0022] FIG. 1 is an electronic bill processing and management
system;
[0023] FIG. 2 is a component model of the system of FIG. 1;
[0024] FIG. 3 is a component model for a provider bill submission
interface for the system of FIG. 1;
[0025] FIG. 4 is an example screen of the submission interface of
FIG. 3;
[0026] FIGS. 5A, B is a further example screen of the interface of
FIG. 3;
[0027] FIG. 6 shows a Labour Management Re-entry workflow of the
system of FIG. 1;
[0028] FIG. 7 is a referrals workflow for the re-entry workflow of
FIG. 6;
[0029] FIG. 8 shows a selection algorithm for the workflow of FIG.
7;
[0030] FIG. 9 is a manage plans workflow for the re-entry workflow
of FIG. 6;
[0031] FIG. 10 shows a first graphical user interface for the
workflow of FIG. 7;
[0032] FIG. 11 shows a second graphical user interface for the
workflow of FIG. 7;
[0033] FIG. 12 shows a third graphical user interface for the
workflow of FIG. 7;
[0034] FIG. 13 shows a fourth graphical user interface for the
workflow of FIG. 7;
[0035] FIG. 14 shows a fifth graphical user interface for the
workflow of FIG. 7;
[0036] FIG. 15 shows a workflow for creating a plan for the
workflow of FIG. 6;
[0037] FIG. 16 shows a first graphical user interface for the
workflow of FIG. 9;
[0038] FIGS. 17A, B shows a second graphical user interface for the
workflow of FIG. 9;
[0039] FIG. 18 shows a third graphical user interface for the
workflow of FIG. 9;
[0040] FIG. 19 shows a fourth graphical user interface for the
workflow of FIG. 9;
[0041] FIG. 20 shows a fifth graphical user interface for the
workflow of FIG. 9;
[0042] FIG. 21 shows a plan versus actuals report workflow for the
system of FIG. 1;
[0043] FIGS. 22, 23, and 24 show a plan versus actuals report
according to the workflow of FIG. 21;
[0044] FIG. 25 shows the components of a predictive payment request
for the system of FIG. 1;
[0045] FIG. 26 shows an interface for a predictive payment; and
[0046] FIG. 27 is a bill generation workflow of the system of FIG.
6.
DESCRIPTION OF THE PREFERRED EMBODIMENTS
[0047] Referring to FIG. 1, an insurance bill electronic processing
and management system 10 has user interfaces 12, 14 for
communicating over a network 16, such as the Internet, information
18 related to insurance bill submission and processing
corresponding to insurance claims. The user interface 14, in the
form of a web browser, facilitates electronic submission of the
bill information 18 from service providers 20 to an integrated
database 26. The integrated database 26 stores the bill information
18 for record keeping. The providers 20 provide insurance related
services to workers 22 making the insurance claims. Management of
the insurance services, provided by the providers 20, is overseen
by a labour management agency 24. The agency 24 uses the user
interface 12 to manage the type and content of the bill information
18 contained within the database 26, as well as coordinating
overall processing and access of the bill information 18. It is
recognized that the workers 22 could also submit electronic bills
through the interface 14 with limited functionality.
[0048] The system 10 supplements the bill information 18 with
general data parameters 28 obtained from an insurance claim
database 30, a provider identification database 32, and an
employers/workers database 34. The data parameters 28 are typically
not specific to any one bill represented in the bill information
18, and include worker addresses, provider names and services, and
insurance claim particulars. A workflow engine 36 (see FIG. 2)
manages the transfer of the bill information 18 and the data
parameters 28 between an adjudication engine 38 and a payment
engine 40. The adjudication engine 38 processes any bills, related
to the insurance claims, resident in the integrated database 26 to
determine what portion of the bills, if any, should be paid out.
The adjudication engine 38 therefore receives bills from the
providers 20, adjudicates the provider bills according to business
rules (including utilization rules), generates adjudication results
for valid "complete" bills, and generates exception records for
invalid "exception" bills. The payment engine 40 then directs
payment of the adjudicated complete bills to a financial
institution 42 for subsequent payment to the providers 20 and/or
workers 22.
[0049] Accordingly, the bill information 18 includes details
related to bill status, such as pending or approved, related claim
data, and bill payment particulars. The providers 20 have real-time
access through the interface 14 to selected bill information 18
contained within the integrated database 26, corresponding to pre
and post processing of the insurance claims and the related bills.
The management agency 24 determines the degree of access by the
providers 20 to the bill information 18 through the provider
procedures 44 (see FIG. 2), which defines the functionality of the
provider interface 14. Real-time accessibility of the bill
information 18 resident on the integrated database 26 facilitates
self-management, by the providers 20, of the bill processing
history once the bills are submitted through the interface 14 to
the integrated database 26. Therefore, the integrated database 26
acts as a repository of bill information 18 and payment information
related thereto.
[0050] Referring to FIG. 1, the management agency 24 uses a support
system 1 for monitoring and setting up the electronic processing
and management system 10. The support system 1 includes a processor
2 coupled to the interface 12. The processor 2 is coupled to a
display 3 for displaying the interface 12 and to user input devices
4, such as a keyboard, mouse, or other suitable devices. If the
display 3 is touch sensitive, then the display 3 itself can be
employed as the user input device 4. A computer readable storage
medium 5 is coupled to the processor 2 for providing instructions
to the processor 2 to instruct and/or configure the various
components of the system 10, including the processes related to
operation of the workflow engine 36 and interfaces 12,14. These
instructions can be used to help set-up and define the protocols
and other procedures related to the operation of the system 10. The
computer readable medium 5 can include magnetic disks, magnetic
tape, optically readable medium such as CD ROM's, and semi
conductor memory such as PCMCIA cards. In each case, the medium 5
may take the form of a portable item such as a small disk, floppy
diskette, cassette, or it may take the form of a relatively large
or immobile item such as hard disk drive, solid state memory card,
or RAM provided in the support system 1. It should be noted that
the above listed example mediums 5 can be used either alone or in
combination.
[0051] Referring to FIG. 2, the functionality of the provider
interface 14 is controlled by the provider procedures 44, which are
predefined by the management procedures 46 according to the desired
degree of accessibility to the bill information 18 resident on the
integrated database 26. The procedures 44 permit the providers 20
through the interface 14 to select bills, update bills, delete
bills, and determine bill status once submitted to the integrated
database 26. Sub-databases of the integrated database 26, directly
accessible by the providers 20 in real-time, are a bill
adjudication queue database 48 and a bill status database 50. The
queue database 48 lists bill information 18 including all bills
(and corresponding bill details) awaiting adjudication, which
preferably are both read and write accessible by the providers 20.
The status database 50 lists bill information 18 including a
pending status (bills undergoing adjudication), a result status
(bill adjudication results), and/or a payment status (bill payment
decision), which are preferably only read accessible by the
providers 20. Real-time inquiry of these bill statuses and queue
are accessible (defined by the provider procedures 44) by the
providers 20 through the interface 14, with detailed breakdowns of
the adjudication and payment decisions determined by the
adjudication engine 38 and the payment engine 40.
[0052] Further referring to FIG. 2, the management user interface
12 allows the management agency 24 to make decisions on the
operation of the system 10, as well as select, delete, update, and
inquire on selected bills submitted by the providers 20 and/or
workers 22. The interface 12 has a set of sub-interfaces of a
predictive payment interface 54, labour market re-entry (LMR)
interface 56, a consultation payment interface 58, and an inquiry
interface 60, which are controlled by the management procedures 46
as defined by the management agency 24. The management agency 24
can also use the interfaces 54, 56, 58, 60 to update the provider
procedures 44 and management procedures 46. The management agency
24 can use the predictive interface 54 and the LMR interface 56 to
define and create individual adjudication rules (utilization rules
UR), related to specific codes (for example LMR codes), for
insertion into the business rule set of the adjudication engine
38.
[0053] Referring again to FIG. 2, the management procedures 46
provide both read and write interaction of the interfaces 54, 56,
58, 60 with the integrated database 26. Interaction between the
interfaces 54, 56, 58, 60 is indicated by arrows 66, which allows
for the sharing of billing data and review functionality between
the interfaces 54, 56, 58, 60, including prepopulation of data
fields. The interfaces 54, 56, 58, 60 have access to the
adjudication queue database 48 and the status database 50 as
described above, with further capabilities such as editing the
operation of the bill queue and amending the bill statuses. The
interfaces 54, 56, 58, 60 also have access to sub-databases of a
bill scheduling database 62 and an adjudication rules database 64.
The scheduling database 62 contains data pertaining to bills
removed from the queue database 48 by the workflow engine 36 for
future processing, and/or data pertaining to predictive bills that
are periodically inserted into the queue database 48 by the
workflow engine 36 for processing by the adjudication engine 38 and
payment engine 40. The adjudication rule database 64 contains
adjudication rules created by the interfaces 54 and 56 in response
to periodic bill parameters for predictive and labour market
re-entry (LMR) insurance claims as controlled by the workflow
engine 36. It is recognized that data for bills related to LMR
insurance claims could also be stored in the scheduling database
62. The degree of access for the read and write interaction of the
database 48, 50, 62, 64 contents could also be limited to various
access levels for individuals of the management agency 24,
depending upon the individuals' priority. The access to the
integrated database 26 from the interfaces 12, 14 can be determined
by role based features for individual providers 20 and employees of
the management agency 24, as well as state based features used as
lock out features to permit sequential rather than parallel editing
of the bill information 18 and data parameters 28.
[0054] Referring again to FIG. 2, the workflow engine 36 monitors
the data content of the sub-databases 48, 50, 62, 64 according to
the management procedures 46, as well as amendment of the rule set
of the adjudication engine 38 by the contents of the rules database
64. The data content of the databases 48, 50, 62, 64 consists of
the bill information 18 and the data parameters 28, which are
supplied by the management agency 24, the providers 20, and the
workers 22. Adjudication and payment details, generated by the
adjudication engine 38 and payment engine 40 respectively, are also
coordinated by the workflow engine 36 into and out of the
integrated database 26, as required. It is recognized that access
of the interfaces 12, 14 to the contents of the integrated database
26 is preferably in real-time. Further, access to the integrated
database 26 by the workflow engine 36 is preferably in periodic or
batch mode to facilitate processing efficiencies, such as providing
lump sum payments to particular providers 20 related to a plurality
of adjudicated bills. However, real-time access of the workflow
engine 36 to the integrated database 26, for adjudication and
payment results, could also be done if desired.
[0055] Referring to FIG. 2, the workflow engine 36 coordinates,
through a defined gather/insert process 66 by the management
procedures 46, the gathering of all adjudication rules from the
rule database 64 for insertion into the adjudication engine 38. The
workflow engine 36 also coordinates a scheduling process 68 for
creating bills from the scheduling database 62 contents, which are
scheduled for insertion into the queue database 48 and the
processed by the adjudication engine 38 and/or payment engine 40 at
specified periodic intervals. The process 68 queries a scheduled
bill table of the database 62 to confirm which bills should be
processed on a periodic cycle, such as a daily cycle, and build any
confirmed bills using minimum bill data requirements for the bill
queue of the queue database 48. Accordingly, the process 68
extracts scheduling data from the database 62, and then decides
whether to hold the bills pertaining to the scheduling data for
future action or to populate the bill queue of the queue database
48 with the extracted scheduling data. This population of the queue
table permits adjudication of the associated bills in sequence
through a query process 70 as described below.
[0056] The workflow engine 36 coordinates the query process 70,
which queries all bills in the database 48 ready for adjudication,
both direct and predictive based. For example, the process 70 will
create an 837 flat file containing all bills obtained from the
database 48, and then transfer the 837 file to the adjudication
engine 36 for processing. The adjudication engine 36 creates an
adjudication results file, such as an acknowledgement 997 flat
file, which is then reviewed by an update process 72 to determine
the degree of success/failure of each bill adjudication. The update
process 72 also transfers the success/failure details of the 997
file to the status database 50, for subsequent review through the
interfaces 12, 14. Further, the update process 72 would also insert
payment details from the payment engine 40, related to the
success/failure details of the 997 file. The workflow engine 36
also coordinates a purge process 74 to purge bills from the queue
database 48 and the scheduling database 62 if needed. For example,
the process 74 will purge all successfully processed bills from the
queue database 48 and all bill schedules from the schedule database
62 that have passed their end date. It should be noted that the
bill tables of the queue database 48 and the scheduling database
62, along with the query process 70 and the schedule process 68
provides an extraction and processing loop for bills of a
predictive nature as entered into the integrated database 26
through the predictive interface and/or the LMR interface 56.
[0057] Referring to FIG. 3, the service provider interface 14 has
four sub-interfaces, namely an initiate LMR bill interface 76, an
initiate bill interface 78, a bill submission search interface 80,
and a void bill interface 82. The interfaces 76, 78, 80, 82 allow
the providers 20 (see FIG. 2) to directly manage electronically
their bill submission and results relating to insurance claims of
the workers 22. The interface 76 allows the providers 20 to submit
bills for payment processing using an electronic version of an LMR
provider invoice, such as an electronic version that conforms to an
EDI claim import (ASCX12N 837) format. The interface 78 allows the
providers 20 to submit bills for payment processing using the
electronic version of a provider payment request, such as for
example the electronic version conforming to the claim import
(ASCX12N 837) format. The interface 80 allows the providers 20 to
execute enquiries on their bill submissions and draft bills
resident on the integrated database 26. These enquiries can include
bill detail, bill history, as well as the status of bill payment
submissions. Preferably for processing efficiency, real time
confirmation of submissions and payment status information may not
be supported, and payment detail may only be available as per a
check run schedule implemented by the payment engine 40. The
interface 82 allows the providers 20 to manage their bill
submissions through void bill actions. For example, in the case of
batch mode operation of the adjudication engine 38 and/or the
payment engine 40, the interface 82 will support same day avoidance
submissions only. Capability could also be included in the system
10 to cancel previously submitted bills once they have been removed
from the bill queue in the queue database 48 for adjudication by
the adjudication engine 38. Accordingly, the interfaces 76, 78, 80,
82 allow the providers 20 to capture bill detail, save draft bills,
export bill detail to the adjudication engine 38, void bill
submissions, and query bill detail and payment status.
[0058] Referring to FIG. 3, the interface 78 has functionality
defined by the provider procedures 44. In particular, the interface
78 has a bill details function 84 of the procedure 44, which allows
the providers 20 to initiate payment requests that are subject to
invalid data, create payment requests and save submissions, create
payment requests and exit submissions, create and submit payment
requests subject to an incompletion, and successfully create and
submit payment requests. It is understood that the bills are
submitted in response to the providers 20 performing or otherwise
providing service, treatment, or products to the workers 22. It is
understood that the workers 22 claims are established with the
management agency 24 prior to submitting the bills, and the
worker/claim entitlement information has been previously loaded
into the adjudication engine 38 and the integrated database 26. The
result of the details function 84 is either a payment request saved
as a draft for future submission or a payment request that is
submitted for processing through the interface 14 to the integrated
database 26. Further, the providers 20 can use a combination of
claim/worker data to submit the bill requests. It is recognized
that the details function 84, and other functions as described
below, could be represented as software modules for use by the
support system 1.
[0059] A first operation of the function 84 is to indicate that a
combination of claims/worker data 89, 91 in the payment request
inputted by the provider 20 is invalid. Referring to FIGS. 4 and 5,
the function 84 provides a submit bill menu 86 to the provider 20,
whereby the provider 20 enters a claim number in conjunction with
worker/patient 22 profile data 91 (see FIG. 5), such as date of
accident, surname, given name, and date of birth, when completed
for submission to initiate the payment request. Other claim data 88
includes service codes, modifiers, ICD-9 codes, date of service,
place of service, units, and dollar amounts. In this instance, the
profile or claim data 88 is determined to be invalid by the
provider procedures 44 and the provider 20 is notified the
claim/patient information is invalid. Accordingly, the error could
be the result of the combination of data 88, 89, 91 being invalid
(e.g. wrong claim/worker combination), the claim number (record)
not existing in the integrated database 26 (i.e. the claim has not
yet been approved/fed into the appropriate components of the system
10), and/or a typographical error on the part of the provider 20
when keying in the requisite validation information included in the
data 88, 89, 91. Accordingly, the invalidation process of the
provider procedures 44 provides a validation mechanism in order for
the provider 20 to proceed with the payment request submission. The
provider 20 is given choices to continue with the request session
on the interface 14.
[0060] Another operation of the function 84 is to create the
payment request and then save the submission in draft for future
editing/submission. Initially, the provider 20 navigates on the
interface 14 to the bill submission component of the menu 86 and
selects the submit payment request submenu option. The provider 20
then enters the data 88, 89, 91 and submits to initiate the payment
request. The provider 20 then confirms patient 22/provider 20
profile information 87, 91 and defines the bill line item
information 88, such as date of service, service code and charge.
The provider 20 then saves the payment request without submitting
the bill to the integrated database 26. For example, a warning
message could be displayed on the interface 78 advising the
provider 20 that the payment request is being saved without
submitting the bill to the integrated database 26. Accordingly, the
provider 20 can then retrieve and submit the bill related to the
saved payment request at a later date, or can delete the draft bill
via the void bill interface 82 as further explained below. It
should be noted, referring to FIG. 5, that the providers 20 have
the ability to input a provider specific invoice as a payment
request to the integrated database 26. The data 88 can contain
multiple bill line items on a per claim basis, which indicates the
specific dates of service for each line and applicable modifiers
(for equipment) of the requests. The provider is given further
choices to proceed with the request session on the interface
14.
[0061] A further operation of the bill detail function 84 is for
the provider 20 to create and exit without saving or submitting the
payment request. Accordingly, the provider 20 navigates on the
interface 14 to the bill submission component of the menu 86 and
selects the submit payment request submenu option. The provider
then enters a claim number in conjunction with patient profile data
91 and submits to initiate the payment requests. The provider 20
also confirms the patient 22/provider 20 profile information 87, 91
and defines the bill line item information 88, however, then
proceeds to exit the request without saving or submitting the bill.
Accordingly, the function 84 displays a warning message advising
the provider 20 that the request is being exited without saving or
submitted. The provider is given further choices to proceed with
the request session on the interface 14.
[0062] A further operation of the function 84 is to initiate
interaction with the provider 20 when creating the payment request,
where some of the required data 87, 88, 89, 91 is incomplete.
Accordingly, the provider 20 selects the submit payment request
from the menu 86 provided by the interface 14, enters the claim
number in conjunction with the patient profile data 91 and submits
to initiate the payment request. The provider also confirms the
patient 22/provider 20 profile information 87, 91 and defines the
bill line item information 88. The provider 20 then proceeds to
submit the payment request, however, a warning prompt appears
informing the provider 20 that the required information is
incomplete and that the payment request will not be dispatched for
the current claim. The provider is given further choices to proceed
with the request session on the interface 14.
[0063] Another operation of the function 84 is for a provider 20 to
create and submit a complete payment request. Once the provider 20
has entered the claim number in conjunction with the patient
profile data 91, and confirmed the patient 22/provider 20 profile
information 87, 91 and bill line item information 88, the provider
procedures 44 check that all of the required information is correct
and then provides the provider 20 with a confirmation prompt
informing that the bill will be dispatched to the integrated
database 26 for payment processing. Accordingly, the provider 20
can select OK and the bill will be submitted for processing, can
select CANCEL and then edit or otherwise discard the payment
request, or if the payment request has been submitted the provider
20 can retrieve from the integrated database 26 the particular
payment request and void the related bill. It is also recognized
that a popup search box for the selection of primary service
provides (POS), representing a list of providers 20 enrolled for
use of the system 10, is accessible by the function 84 for
completing the payment request.
[0064] Referring to FIG. 3, Labour Market Re-entry (LMR) bill
interface 76 of the general provider interface 14 enables LMR
providers 20 to submit LMR invoices to the management agency 24 for
payment via electronic submission provided by the system 10. The
LMR bills are for service, treatment, or products
provided/performed by the provider 20 according to an approved LMR
plan as accommodated for in the integrated database 26 and the
adjudication engine 38. The approved LMR plan includes a budget
amount relating to the types of service, treatment, and/or product
provided or performed by the provider 20. Each of the types is
referred to as a line of service. It is recognized that the
utilization rules (UR) of the rules database 64 have been loaded by
the work flow engine 36 into the adjudication engine 38 prior to
submission of the LMR invoice. The provider procedures 44 contain
an LMR bill detail function 92 for coordinating the creation and
submission of LMR invoices (payment requests). It is noted that the
LMR providers 20 can identify the combination of claim/patient
profile information 89, 91 to proceed with a payment request
submission through the validation mechanism, as described above in
relation to the function 84. Further, the LMR providers 20 can
submit multiple lines of service as bill line items 88 on a per
claim basis and can identify an SSP for each of the lines of
service. Further, the LMR providers 20 also indicate specific dates
of service for each line of service included in the data 88 as well
as indicating applicable modifiers (for equipment) in the LMR
invoices. In addition to that described above for the function 84,
the function 92 also allows the LMR provider 20 to identify the
secondary service provider (SSP) for which the bill line items 88
apply. Preferably, only one SSP is identified per bill and all line
items 88 are associated accordingly. Further, the function 92 also
operates with a search popup page 94, which is supplied to the
provider 20 through the interface 76. The popup page 94: the
provider 20 to search and select appropriate SSPs. In addition,
further popup pages of an expense code 96 and an ICD-9 98 can be
provided by the function 92 to the interface 76 to allow the
provider 20 to clarify and confirm portions of the data 88
corresponding to expenses and ICD-9 information. Accordingly,
similar to the function 84, the function 92 also allows the
provider to select OK for submitting the LMR invoice for
processing, selecting CANCEL and/or EDIT discard features for the
LMR invoice, and if the invoice has been previously submitted the
provider 20 can retrieve and void the invoice. Further, more than
one SSP can be selected through the popup page 94 to be included in
the LMR invoice.
[0065] Referring to FIG. 3, the sub-interface 82 of the general
provider interface 14 enables the providers 20, both payment
requests and LMR invoices, to cancel bill submissions and/or draft
bills. It should be noted, for batch mode operation of work flow
engine 36 the voiding of bills may only be available for same day
cancellations, or any other period specified for the batch mode. It
is assumed that prior to accessing the VOID bill page interface 82,
the provider 20 has already submitted the bill payment request,
saved as a draft the bill payment request, and/or has decided to
proceed with a same day (or other period) review/cancellation
process. Accordingly, the provider procedures 44 allow the provider
20 to navigate to the VOID bill submission interface 82, whereby
the provider 20 selects the draft or submitted bill to be cancelled
via a check box (for example, "Void bill ?") and the submit a VOID
request (for example by a "Void selected" button). See scenarios
below discussed users guide and example screens for the interfaces
14, 76, 78, 80, 82. It should be noted that multiple bills can be
voided simultaneously through the VOID interface 82. Once the VOID
request has been received by the integrated database 26, a
confirmation message is displayed on the interface 82 to the
provider 20 thereby informing the provider 20 that the selected
bills will be cancelled. The provider 20 is given the option to
select OK for the bills to be cancelled or to select cancel so that
the VOID selections will be cleared and therefore not voided from
the integrated database 26, through operation of the process 74
implemented by the work engine 36.
[0066] Referring to FIG. 3, the bill submission search interface 80
of the general provider interface 14 enables the providers 20, for
both payment requests and LMR invoices, to investigate the
adjudication and payment status of bills submitted to the
integrated database 26. For batch mode operation of the work flow
engine 36, real-time confirmation of submissions and payment status
information may not be supported. Moreover, payment detail may only
be available as per a check run schedule as implemented by the
payment engine 40. The interface 80 has a bill submission search
results function 100 as part of the provider procedures 44. The
function 100 allows the provider 20 to retrieve bills/payment
details from the databases 48, 50 of the integrated database 26 by
a variety of search parameters, such as claim-invalid, claim
number-valid, date range-invalid, data range-valid, status-invalid,
status-valid, claim number and date range, and status and claim
number. It is further recognized that other combinations of search
parameters, including or excepting those above, can also be used
for treating the bill/payment details from the integrated database
26. It is noted that SDT inquiry functionality and design can be
leveraged for the provider 20 inquiry implemented by the interface
80. The 16 search function 100 co-ordinates the display of either a
bill details page 102 or a payment details page 104 on the search
interface 80.
[0067] Operation of the function 100 is initiated when the provider
20 navigates to the bill payment inquiry component of the menu 86
of the general interface 14 (see FIG. 4). The provider 20 enters a
claim number to filter the claims by and then submits. However, in
one case the claim number entered may be invalid, and therefore an
error message is displayed on the interface 80 by the search
function 100 informing the provider 20 that no bill exists for that
claim. The provider 20 can then select different claim numbers or
parameters and then re-submit. Accordingly, the provider 20 can
investigate adjudication results and payment details for submitted
bills. An alternative to the above operation is when the provider
20 enters the claim number to filter the claims by, which contains
a valid claim number, and therefore a list of bills is provided by
the function 100 for the appropriate claim number for display on
the interface 80. The interface 80 can display the inquiry results
as the bill detail page 102, the payment detail page 104, or a
combination of both. Further, upon the inquiry for a valid claim
number, the provider 20 can narrow the search by the
finding/modifying additional criteria. As well, the provider 20 can
select a particular bill (such as a link pertaining to a particular
bill ID) to be viewed in greater detail. Accordingly, the function
100 interacts with the bill detail function 84 or the LMR bill
detail function 92 to retrieve the requested bill detail.
Alternatively, the provider 20 can select a paid amount (such as a
link for a particular payment) to be viewed in detail. The function
100 can then interact with the bill detail function 84 or the LMR
bill detail function 92 to retrieve required details for display on
the bill detail page 102 or the payment detail page 104 on the
interface 80.
[0068] A further operation of the search function 100 allows the
provider 20 to retrieve bills/payment detail information by date
range. The provider 20 enters a start/end date range or uses a
calendar control to select a date to refine the search results by,
and submits through the interface 80. The search function 100 then
checks the date range against the bill details stored in the
databases 48, 50, and for example can return with an invalid date
range entered by displaying an error message on the interface 80
informing the provider 20 that no bills exist in the integrated
database 26 for the date range selected. The provider 20 can then
select a different date range or parameter and re-submit on the
interface 80 through the search function 100. An alternative to the
above is when the date range entered by the provider 20 is
considered valid by the search function 100. In this case, a list
of bills previously submitted by the provider 20 for the date range
parameters selected is displayed on the interface 80. Accordingly,
the provider 20 can narrow the search by defining/modifying
additional criteria and can select either a particular bill and/or
a particular paid amount to be viewed in greater detail. It should
be recognized that multiple bill/payment details can be accessed
through the general interface 14 simultaneously, as long as they
correspond to the selected search criteria submitted through the
interface 80 to the search function 100.
[0069] A further operation of the search function 100 is retrieving
bill/payment detail information by status. The provider 20 selects
the status range to filter submitted/draft bills by and then
submits this to the search function 100. The search function 100
then proceeds to review the contents of the databases 48, 50. If
the status selected is invalid, then an error message is displayed
on the interface 80 informing the provider 20 that no bills exist
for the status selected. The provider 20 can then select a
different status or other parameter and re-submit the new search
criteria to the search function 100. An alternative to the above is
when the status criteria are considered valid by the search
function 100. In this case, the status selected produces a list of
bills matching the selected status, subsequently displayed on the
search interface 80. As note above, the provider 20 can then narrow
the search by defining/modifying addition search criteria and/or
can select particular bills and/or paid amounts to be viewed in
greater detail.
[0070] A further operation of the search function 100 is to
retrieve bill/payment detail information from the databases 48, 50
by claim number and date range. Accordingly, the provider 20 enters
a start/end date range to refine the search results and then enters
a claim number to filter the claims by and then submits the search
request to the search function 100. The search function 100 then
searches through the databases 48, 50, and if valid, provides a
list of bills previously submitted by the provider 20 for a given
claim during the date range parameters specified for display on the
interface 80. As noted above, the provider 20 can narrow the search
further by defining/modifying additional criteria. Another
operation is that the provider 20 can retrieve bills/payment detail
information by specifying status and date range. Accordingly, the
provider 20 enters into the interface 80 a start/end date. range to
refine the search results, then selects a status range to filter
submitted/draft bills by, and then submits the search request to
the search function 100. The search function 100 retrieves the
matching bills, if valid, from the databases 48, 50 with a selected
status during the date range parameters for display on the
interface 80. The provider 20 can then narrow the search by
defining/modifying additional criteria as noted above. A further
operation of the search function 100 is to retrieve bill/payment
detail information by status and claim number. The provider 20
enters a claim number to filter claims by and submits and selects a
status range to filter submitted/draft bills by and submits. For a
valid combination the claim number/status criteria is searched by
the search function 100 in the databases 48, 50 to provide a list
of bills usually submitted by the provider for a given claim during
the given status for display on the interface 80. As noted above,
the provider 20 can narrow the search by defining/modifying
additional criteria.
[0071] A further operation of the search function 100 is to
retrieve a saved payment request, modify the bill detail, and the
submit to the integrated database 26 for payment processing through
the work flow engine 36. This operation can be done by the provider
20 when bills have been created and saved for future processing.
Accordingly, the provider 20 navigates to the bill/payment enquiry
component of the menu 86 and then proceeds to enter a combination
of search parameters to retrieve a list of bills (both active and
pending). The parameters can include claim number, bill status,
data range, and provider information. The provider 20 can then
select from the list displayed on the interface 80 a particular
bill with a status of pending. The details of the pending bill are
displayed on the interface 80 and the provider 20 can make any
necessary changes/additions of the draft bill. The provider 20 is
then given the opportunity to submit the payment request, if the
bill request is now complete, and then a confirmation prompt can
appear on the interface 80 informing the provider 20 that the bill
will be dispatched to the management agency 24 for payment
processing. The provider 20 can select OK and the bill will be
submitted to the integrated database 26 for processing, can select
CANCEL and thereby edits/discard the bill, or if the bill has been
submitted previously the provider 20 can retrieve and void the bill
using the void interface 82.
[0072] The following outlines example interface 14, 76, 80, and 82
screens for a first scenario of submitting the payment request, a
second scenario of submitting an LMR invoice, a third scenario of
bill payment status enquiry, and a fourth scenario of voiding a
bill. Further to that already described above, the scenarios 1, 2,
3, and 4 demonstrate the ability to provide multiple bill line
items per claim for display on the appropriate interface 14, 76,
78, 80, 82, and the interaction of popup boxes for service code
searches, date of service selections, LMR expense codes, and
provider searches. Further, the enquiry and void scenarios allow
the retrieval and subsequent selection of multiple bills per page,
as displayed on the appropriate interface 80, 82, to facilitate
easy of selection by the provider 20.
[0073] Further, an application user guide is provided for the LMR
submission interface 76, the bill submission search interface 80
and void interface 82, appropriate either to LMR and/or bill
payment requests. It should be noted, that the user guide explains
further functionality of the system 10 such as printing a screen
with bill information 18 contained thereon, and system 10 login for
providers 20 part of a provider database having access to the
system 10. It should be noted that registry opportunities for an
unregistered provider 20 is also presented on the general provider
interface 14. It should be noted that the user guide should be
considered as one example of system 10 application to a specific
management agency 24. Accordingly, some of the required criteria
for entry into the data fields as displayed on the interfaces 14,
76, 80 may be other than those shown.
[0074] Also provided in this disclosure is an example
implementation of the system 10 for provider bill submission UI web
specification and error/warning messages. The web specification
gives examples of the controls listed in the tab sequence of the
menu 86 and sub menus thereto, as well as the actions or events
required on the various pages displayed on the interfaces 14, 76,
78, 80, 82 to initiate the corresponding listed responses. Further,
the web specification also includes example data elements and data
validation parameters.
[0075] Referring to FIG. 6, the LMR workflow 199 is shown between
the worker 22, the management agency 24, and primary (PSP) and
secondary (SSP) service providers. Initially, the worker 22 submits
a plan request 200 to the management agency 24. The management
agency then uses an adjudicator 24a to compose a plan referral 202,
which is sent to a selected provider PSP. The PSP accepts the
referral 202 and submits a completed or proposed plan 204 back to
the management agency 24. The completed or proposed plan 204
includes a listing of expenses with corresponding SSPs, dollar
amounts, start dates, and end dates. The adjudicator 24a in
conjunction with a health care professional 24b reviews the plan
and submits the approved plan 206 back to the PSP. The PSP can then
sub-contract out portions 208 of the plan 206 to a number of SSPs.
It is noted that there may be situations in which the plan 204
requires amendment and the referral 202 may be declined, as further
described below. Further, once the approved plan 206 is confirmed,
a rule set 210 is sent by the management agency 24 into the rules
database 64 (see FIG. 2), which eventually is inserted into the
adjudication rule set of the adjudication engine 38. The rule set
210 is used to identify whether bills are payable under the
approved plan 206 by testing the bills against the rules. The rules
include that the SSP on the bill is the same as the SSP on the line
of service, that the date of service of the bill in within the
range for the corresponding entry in the plan, and that the amount
of the bill is less than the amount remaining in the plan budget
for the corresponding line of service.
[0076] The PSP and SSP have access through the interface 14 (see
FIG. 2) to the integrated database 26, for subsequent inquiry of
the approved plan 206 as it is processed through the system 10. It
should be noted that the approved plan 206 enables the management
agency 24 to pre-approve a group of bills associated with the
particular LMR plan 206. It should also be noted that it is
preferable that only the intended provider PSP have access to the
referral 202 through the interface 14.
[0077] Referring again to FIG. 6, the LMR workflow 199 is designed
to assist the workers 22 who have injuries that prevent a return to
work with the accident employer. The management agency 24 partners
with the providers PSP, SSP to deliver skills acquisition and
training programs. The management agency participates in the
workflow 199 by initiating referrals 202, approving plans 206,
monitoring programs, and helping to pay bills associated with the
approved plans 206 through payors (not shown) who provide payment
as specified by the payment engine 40 (see FIG. 2). Accordingly,
the referrals 202 mark the starting point for the LMR workflow 199,
as the worker 22 receives LMR services preferably through the
referral 202 from the management agency 24 to the provider PSP. The
provider PSP submits the proposed plan 204 to the adjudicator 24a
who then indicates approval or requests changes. Once the plan is
approved, the approved plan 206 provides the details needed to
adjudicate LMR bills.
[0078] Once the plan 204 has been approved, bills can be submitted
by the providers PSP, SSP to the IDB 26 (see FIG. 1) and paid
according to the details in the plan 206, as further described
below. The providers PSP, SSP incur costs in performing the LMR
plan 206 for the worker 22. The providers PSP, SSP can then submit
their bills through the interface 14 to the IDB 26 for their own
expenses and for expenses incurred on behalf of the worker 22. The
LMR bills are adjudicated by the adjudication engine 38 (see FIG.
2) and payment is determined by the payment engine 40 according to
the rules established 210 previously upon plan approval. LMR bills
that fall within entries in the plan and match plan requirements
are approved by the adjudication engine 38 for payment. The rules
210 verify that the bills fall within the date requirements and
budget requirements of the plan. Other bills are sent to a person
for a manual check of the bill's eligibility for payment.
[0079] Referring to FIG. 7, a send referrals process 212 starts 214
where the adjudicator 24a creates 216 the LMR referral 202 (see
FIG. 6). The adjudicator 24a submits 218 the referral 202 for
review by the nurse case manager 24b, who completes 220 the review
and returns 222 the referral 202 to the adjudicator 24a. The
adjudicator 24a receives 224 the referral 202 and sends 226 the
referral 202 to the provider PSP, who can retrieve 228 the referral
from the interface 14 (see FIG. 1) of the system 10. If the
provider PSP accepts 230 the referral 202, then the referral 202 is
assigned 232 to a consultant of the provider PSP to generate 234
the proposed plan 204. Further, the adjudicator 24a is notified 236
that the referral 202 has been accepted and the referral process
212 ends 238. Otherwise, the provider PSP declines 242 the referral
and an alternate provider PSP is selected 244. This selection 244
continues until acceptance 236 is confirmed.
[0080] It should be noted that the referral process 212 can
automatically select the provider PSP from the provider database 32
(see FIG. 1). Referring to FIG. 8, a selection algorithm 246
accesses 248 the database 32 through a plurality of selection
criteria 250. The selection criteria 250 can include postal code
matching 252 of the provider PSP and the worker 22 (geographic
specific), provider expertise 254, provider selection frequency 256
for distributing a number of referrals among a group of eligible
providers PSP, or any other combination of the above. It is
recognized that other selection criteria can be used, if desired.
Once the provider PSP is selected 258, the adjudicator 24a or other
system administrator can override 260 the selection. It is also
possible that the adjudicator 24a manually selects the provider PSP
for the referral 202.
[0081] Referring to FIGS. 10-14, an example referral 202 is shown,
including worker 22 details, employment profile, physical
precautions, referral details, as well as provider details that can
be determined by the algorithm 246 (see FIG. 8). 10
[0082] Referring to FIG. 9, a manage plans process 262 starts from
the previous step 234 of the referral process 212. The provider PSP
creates 264 the proposed plan 204 (see FIG. 6) and submits it
through the interface 14 (see FIG. 1) to the management agency 24.
The agency 24 then receives 266 the proposed plan 204. The agency
24 determines 268 a value for the proposed plan 204 and then sends
payment 270 to the provider PSP for the plan set-up and what level
of assessment has already been completed with the worker 22.
Further, the agency 24 also reviews 272 the proposed plan 204 for
suitability. If the plan 204 is approved 274, then the adjudication
rules 210 are determined and sent to the rules database 64 for
subsequent use in adjudicating LMR plan bills associated with the
approved plan 206. The provider PSP is notified 276 of the
approval. Otherwise, the plan 204 is declined and amended 274, and
the provider PSP is notified 278 that changes are required before
final approval. The provider PSP then modifies the plan 204 and
resubmits 280 it for approval. This change process can continue
until the plan 204 is finally approved 274.
[0083] Further activities by the provider PSP and management agency
24 for the process 262 include the provider PSP viewing the status
of the submitted plan 204, 206, the provider PSP submitting plan
206 amendments as necessary after approval, the provider PSP
viewing the balance remaining on approved plans 206, and the agency
24 changing the status of the plans 204, 206 (i.e. cancel, suspend,
reactivate). In the case of changes or amendments of the approved
plan, the rules 210 are also updated to reflect the changes.
Further, during the amendment process of the plans 204, 206, all
versions of the plans 204, 206 can be stored in the IBD 26 (see
FIG. 2) for referral by the agency 24 to help in subsequent
analysis of the plans 204, 206.
[0084] Therefore, as described above, the process 212 creates and
sends the referral 202 to a selected provider PSP, who then either
accepts or declines. Notification of the acceptance/decline status
is given to the agency 24. Further, it should be recognized that
once the initial referral 202 is created, all subsequent status
information of the referral 202 is stored in the IDB 26 (see FIG.
2) for review by interested parties of the system 10 through the
interfaces 12, 14. Following acceptance of the referral 202, the
provider PSP prepare and submit the proposed plan 204, which can
consist of information pre-populated from the referral 202, an
indication of the level of assessment completed with the worker, as
well as details outlining the proposed program of care. After the
plan 204 is submitted, the referring adjudicator 24a receives
notification of the plan 204 and initial payment is given to the
provider PSP base on the indication of the level of assessment
completed. Therefore, it should be noted that the rules 210 are
used by the adjudication engine 38 (see FIG. 2) to process the
remaining level of assessment of the approved LMR plan 206 on a
predictive basis.
[0085] The adjudicator 24a indicates initial adjudication results
on the proposed plan 204, and have the option of either approving
the plan 204 or requesting changes. The approved plan 206 triggers
through the workflow engine 36 (see FIG. 2) the creation and
submission of the payment rules 210 into the adjudication engine
38. These results are also accessible through the interfaces 12, 14
for interested parties. As discussed above, the providers PSP can
also request amendment of the approved plan 206, however,
preferably the initial level of assessment remains static. If
amended, the adjudicator 24a is notified of the amendments and the
amended plan 206 must be reapproved. It should be noted that the
status and details of the amended plan 206 are stored in the IDB 26
(see FIG. 1) for access through the interfaces 12, 14. In the case
of subsequent reapproval, the rules 210 are triggered for change
and reinserted into the adjudication engine 38. Accordingly, the
revised rules 210 replace the previous rule set 210. Further, the
adjudicators 24a can change the status of the plan 206 at any time,
such as to suspension or cancellation. This change in status is
recorded in the IDB 26, as well as revised in the rules 210 to
deactivate the payment associated with the plan 206. Conversely,
the adjudicators 24a can also reactivate the plan 206, if suspended
or cancelled, which will also trigger the revision of the rules 210
to reactivate the payment rules associated with the plan 206. It
should be noted that this change in status is also recoded in the
IDB 26. Accordingly, the interfaces 12, 14 can be used by
interested parties (i.e. agency 24 members and providers PSP) to
inquire about the status and other details concerning referrals 202
and plans 204, 206, as well as the actual dollar amounts
approved/paid against the plan 206.
[0086] It is also recognized that members of the agency 24 can
override any provider PSP selection, change the PSP, view a series
of referrals 204 against associated valid claim numbers, and view
plans 204, 206 and amendments for any valid claim number. Further,
members of the agency 24 can also update LMR parameters of the
system 10, including the referral algorithm 246 operation, the
selection criteria 250, as well as expense codes and dollar limits
used by the plans 204, 206.
[0087] Referring to FIG. 15, an example creation or editing of the
plan 204, 206 is shown. An example plan 204, 206 is shown in FIGS.
16 to 20. In general, the creation of the plan 204, 206 includes:
[0088] 1. User (of the provider 20 see FIG. 2) logs into the system
10 through the interface 14, [0089] 2. User selects the view or
edit plan option, [0090] 3. System 10 displays the following
fields: Claim Number, Worker First Name, Worker Last Name on the
interface 14, [0091] 4. User enters worker's name and or claim #,
[0092] 5. User issues a Search command, [0093] 6. System 10
searches for matching criteria and validates that the claim number
is a 28 valid claim number, [0094] 7. System 10 determines that the
claim number is valid and displays the results to the user on the
interface 14, [0095] 8. System 10 displays the following fields to
the user for the specific claim number:
[0096] Section 1: Plan Header Tab (see FIG. 16) [0097] Claim number
[0098] Claim status [0099] Worker name (first and last) [0100]
Worker DOA [0101] Desk ID [0102] Plan ID [0103] Plan Version [0104]
Plan Status [0105] Date Plan Created [0106] Plan Start Date [0107]
Plan End date [0108] Plan Review Date [0109] Plan Suspension Period
[0110] date Plan Last Modified [0111] Plan Modified By
[0112] Section 2: Payment Details Tab (see FIG. 17) [0113] Status
[0114] Service Code [0115] Freq [0116] Unit [0117] Amount [0118]
Payment Start Date [0119] Payment End Date [0120] Payee Name
[0121] Section 3: Assessment Tab (see FIG. 19) [0122] PCA Total
Amount [0123] CA Total Amount [0124] Rationale Notes for assessment
detail
[0125] Section 4: CEW Tab (see FIG. 19) provides a summary of the
various cost categories and Section 5: View Payments Tab (see FIG.
20) provides summary of approved amounts once the plan 204 has been
submitted and then reviewed by the adjudicator 24a (see FIG.
6).
[0126] In order to display the actual dollar amounts approved
and/or paid against the plan 206, the facility to create a report
called plan budget versus actuals is provided within the reporting
and monitoring module (see FIG. 1). The name "actuals" refers to
the actual dollar amounts paid. The plan versus actuals report uses
details of the plan described above and stored in the integrated
database. The report also uses information on the amounts paid
which are also stored in the integrated database.
[0127] Referring to FIG. 21, a workflow for creating a plan versus
actuals report is shown generally by the numeral 320. A report may
be requested by a primary source provider (PSP) or by the labour
management agency (LMA) 24. At step 322, the PSP or the LMA
requests the plan versus actual report. The request includes a
claim number as an indication of the plan of interest. The plan
budget versus actual report provides a view of the entire plan
including budgeted amounts compared to paid amounts. To create the
report, the system determines the latest approved plan at step 324.
Although the plan is the "latest approved plan", the status of the
plan may be "closed" or "expired" rather than "approved". The
system then finds all paid bills for the claim indicated in the
request at step 326. The claim number and service code on each bill
will determine which section the bill will be counted against.
[0128] The system then aligns all the paid bills with the latest
approved plan associated with the claim indicated in the request at
step 328. The aligning process uses the bill service code to align
bills with plan lines according to their service codes. The bill
date of service (DOS) can be outside of the date range defined for
the plan line service. The bill secondary service provider (SSP)
can be different from the SSP defined for the plan line
service.
[0129] This system then displays the report at step 330. A sample
report is shown at FIGS. 22, 23, and 24. The report is displayed in
two sections, namely, a header and a body. The header section
includes the following information:
[0130] "As of": date the information that is displayed was
updated
[0131] "Worker name": Last and First name of worker associated with
the case
[0132] "Claim Number": claim number associated with the case
[0133] "Plan Id": LMR Plan Id generated by the system
[0134] "Version": Version of the LMR Plan
[0135] "Plan States": status of the LMR plan information
displayed
[0136] "Effective Dates": [0137] From is the date when the plan was
last approved [0138] To relates to plan Status: [0139]
Approved=open [0140] Closed=date when the plan was closed [0141]
Expired=date the plan expired
[0142] "Service Duration": the earliest start date of a service in
the plan to the latest end date of a service in the plan. Note:
Service duration can be outside the plan effective dates. "Case
Manager Name and Phone": Last and first name of Case Manager and
phone "Adjudicator Name and Phone": Last and First name of
Adjudicator and phone "Primary Provider and Location": Name of
Primary service Provider and location (city) "Transferred From",
"Location" and "Transfer Date": when plan is transferred, the
previous owner name, location (city) and date when plan is
transferred. Transfer can be External (from another provider) or
internal (from a different location or different Case Manager). If
the case was not transferred, "n/a" will be displayed in these
fields.
[0143] Within the body of the report are four sections, namely
assessment, plan budget with actuals, other payments issued, and
totals. The assessment section includes the services of
transferable skill analysis, evaluation, and vocational evaluation.
The report displays the service code and name of assessment
services that have been paid automatically. The report also
displays the code and name of the primary service provider
associated with the auto-payment. Finally, the report shows the
actual amount paid to the primary service provider. If no amount
has been paid, then the message "no assessment" is displayed.
[0144] The plan budget with actuals section of the report displays
all services in the latest approved plan with the actual amounts
paid for each service grouped by secondary service provider (SSP).
The report includes the service code and name according to the
latest approved plan. The provider code, name and address according
to the latest approved plan, the effective dates of the service
according to the latest approved plan, the status of the service,
the plan amount and the actual amount paid to the secondary service
provider. The status of the service can be "current", "future",
"past" or "unallocated". The status is "current" if the date is
between the start date and end date of the plan line service. In
this case, the "actuals" amount is the total of bills where the DOS
is between the service start date and end date, the bill service is
the same as the line service, and the bill SSP is the same as the
line service SSP.
[0145] The status is "future" if the date is before the start date
of the plan line service. In this case, the "actuals" amount is the
total of all bills where the bill DOS is between the service start
date and end date, the bill service is the same as the line
service, and the bill SSP is the same as the line service SSP.
[0146] The status is "past" if the date is after the end date of
the plan line service. In this case, the "actuals" amount is the
total of all bills where the bill DOS is between the service start
date and end date, the bill service is the same as the line
service, and the bill SSP is the same as the line service SSP.
[0147] The status is "unallocated" if the bill service is the same
as the line service, and the bill SSP is not the same as the
service SSP or the bill DOS is outside of the range defined by the
start date and end date of the plan line service or both.
[0148] Finally, the system calculates the balance remaining in the
plan as the difference between the plan amount and the actual
amount. For each separate service, the report includes a service
total line which includes the total budget for that service and the
actual amount paid for that service and the balance available for
that service.
[0149] The other payment section of the report displays all
payments made for services that are not in the latest approved
plan. This section of the report displays the service code and name
for payments made for a service outside of the latest approved
plan, the code and name of the service provider associated with the
payment, and the actual not paid. If there is no such payments then
a message is shown saying "no other payments were issued."
[0150] The total section of the report shows the actual amount paid
for assessments, the plan amount, actual amount and balance for the
plan budget with actual section, the total of other payments
issued, and an overall total of all actual amounts paid for the
claim.
[0151] As discussed above, the predictive payment process 119 (see
FIG. 6) is part of the system 10. The recurring payment requests
associated with the LMR plans 206 are used in the administration of
worker 22 claims in order to support the bill adjudication 38
process. There are four major functions used in the system 10 and
associated process 199, including creation of a predictive payment,
the modification of a predictive payment, searching for existing
predictive payments, and a bill generation process. These functions
are coordinated through the interfaces 12, 14 (see FIG. 1).
[0152] Referring to FIG. 26, the following steps are performed to
create a predictive payment: [0153] 1. The Plan 206 Start Date is
auto-populated based on the earliest payment start date on the that
will be entered on the Plan Detail tab; [0154] 2. The Plan End Date
can be automatically populated by the system to 5 years, for
example, from the Plan Start Date. This date can be modified by the
user to a date other than the preset date, if desired; [0155] 3.
The system will auto-populate the Plan Review Date to 12 months,
for example, prior to the Plan End Date; [0156] 4. Next the user
moves to the Payment Detail tab of the page (see FIG. 26) and
begins building the plan 206; [0157] 5. User selects the
appropriate service code. User may select the service code from the
predefined pick list which will highlight their selection to flag
to the user what they have chosen or they may click the Other
Service Code icon which will open the scope of the service code
search to all service codes. The user can search for the service
code based on keyword and or by service code number; [0158] 6.
System 10 displays the selected service code in the Service Code
field. The service code description will be displayed below the
service code field. System will determine if selected service code
belongs to a pre-defined group or "bundle" and will automatically
pre-populates the next detail line items with all the service codes
within that "bundle"; [0159] 7. User moves to the Frequency field
and indicates the appropriate frequency from the predefined pick
list (if required, this is a mandatory field but is sometimes
populated by system logic); [0160] 8. System 10 highlights and
displays the user's frequency selection in the pick list; [0161] 9.
User moves to the Unit field and enters the numeric number of units
to help determine the dollar value of the payment. For example, the
unit value entered is equivalent to the total number of hours
allowed for that service per month; [0162] 10. User moves to the
Amount field and enters the dollar amount of the payment (if
required, this is a mandatory field but is sometimes populated by
system logic) and is displayed to the user. [0163] 11. User moves
to the Payment Start Date and enters the date that the first bill
should be generated to begin the recurring payment cycle. A
calendar icon can be available to the user in order to facilitate
the user in the date selection process; [0164] 12. User moves to
the Payment End Date and if needed alter the default date of Dec.
31, 9999 that the last bill should be generated to end the
recurring payment cycle. A calendar icon can be available to the
user in order to facilitate the user in the date selection process;
[0165] 13. The payee field can be pre-populated with the worker's
22 name, however, the user may change payee as required (i.e. to
the worker's trustee.) by moving to the Payee field. User can click
on the Payee icon so that they may search for the appropriate
payee. The user will be able to search for the payee based on their
name (first and or last) and or Provider TIN# which will have
already been set up for the payee whether they be a worker,
supplier, provider or third party; [0166] 14. System 10 will
display the full address of the Payee to the user, the user will
click on the payee ID and the system will populate the payee field
in the Payment request Section with the full name of the payee;
[0167] 15. It is assumed that the payee will be the same for all of
the payment requests. Once Payee field has been changed, the system
10 will make active a checkbox entitled All Payee, which will be
checked. The user can uncheck this checkbox which means that for
every payment detail they now enter for the plan 206, a payee will
have to be selected and all payee name fields on the page will be
deleted; [0168] 16. User may repeat steps 10-21 for every different
payment request 304 they wish to set up for this predictive payment
plan 206; [0169] 17. System 10 will also allow the user to
"de-select" a payment detail automatically created based on service
groupings (Step 13); [0170] 18. User moves to the Rationale Tab of
the page and if needed in the Rationale Notes field enter any
additional information. The system will pre-populate the PCA Total
Amount and CA Total Amount fields. The CA Total Amount is equal to
the total amount of clothing allowance paid per year to the worker
(system 10 adds all clothing allowance service codes to be paid for
the year). This amount does not include arrears amount. The PCA
Total Amount is equal to the total amount of Personal Care
Allowance paid per month (system 10 adds up all PCA service codes
to be paid for the month into one amount). This amount does not
include arrears amount; [0171] 19. User issues the Save command.
System saves the information to the database and the predictive
plan is successfully saved with a status of "Pending" allowing the
user to save a partially completed plan. To activate the plan 206,
user will go to the Modify Plan option and completed all required
information; [0172] 20. User issues the Submit command on the
Rationale tab; [0173] 21. System 10 can run validation checks for
completeness on mandatory fields and format of data entered into
all fields that require population by a user and ensuring that no
duplicate payment requests have been created; [0174] 22. System 10
saves the information to the database 26 (see FIG. 2) and the
predictive plan 206 is successfully saved as "Active".
[0175] The create predictive payment process involves the set up of
one or many predictive payment requests by the rules 210 for the
purposes of the predictive payment plan for the worker 22 claim.
The modify predictive payment process involves the application of
the administrative practices of a payor to the existing predictive
plan structure they have defined for a worker 22 claim. These
modifications may include the following changes: modify service
code; modify frequency; modify payment amount; modify start and end
dates; modify units (where applicable); and modify payee. These
items are included in the LMR DB 64 (see FIG. 2) as the series of
payment rules 210, which are imported into the adjudication engine
38 once the plan is confirmed. The search process involves
retrieving and displaying information about the predictive payment
plan 206 for the worker 22 claim based upon user specified criteria
through the interfaces 12, 14, which can be used to obtain up to
date information on the status and activity of the plan 206 as
stored in the IIDB 26 (see FIG. 2). The bill generation process
involves the triggering of bill creation based on parameters
defined during the predictive payment plan 206 maintenance (create
and modify) processes. The bill generation process will apply logic
through the workflow engine 36 and the adjudication and payment
engines 38, 40 so that recurring payment requests will occur, which
are associated with the details of the approved plan 206 and
corresponding rules 210.
[0176] There are three main concepts that make up the functionality
of the Predictive Payment process 119 as implemented on the system
10; namely referral, maintenance of predictive payment plans 206,
and generation of bills from predictive payment plans 206. The
predictive payment plan 206 (or PPP) is a collection of one or more
payment requests with corresponding payment parameters such as
amount, frequency, start and end dates, which are then organized in
a structure for the purposes of plan definition. From the plan
definition the bill generation process will then be triggered to
generate bills for specific payees as per the specified frequencies
and start and end dates for the payment requests that are specified
in the plan 206. The PPP is comprehensive meaning that it will
include all of the predictive payment requests that a worker 22
claim needs in order to be able to build plans 206. The predictive
payment plan 206 contains at least one predictive payment request
and at least one payee.
[0177] Referring to FIG. 25, a Predictive Payment detail 300
includes the plan that interacts through a payee 302 with the
predictive payment request 304 (embodied in the rules 210, see FIG.
6). The payment request 304 identifies a service code 306,
frequency 308, units 310, amount 312, and payment request start 314
and end 316 dates. For example, the agency 24 will determine that
the worker 22 claim is entitled to a Personal Care Allowance and
will then set up a predictive payment request 304 by the rules 210,
which will allow a recurring payment to be sent to the specified
payee 302. The agency 24 can indicate during the creation process
which Personal Care Allowance code the worker 22 will receive
reimbursement for, the frequency for which the worker will receive
reimbursement, the number of units, the amount of the
reimbursement, and the start date and end date for the
reimbursement period. The payee 302 identifies who will receive
reimbursement for the predictive payment request or requests 304.
The agency 24 may indicate at the plan level the payee 302 if all
the payment requests--304 go to the same payee 302 or if there are
multiple payees 302 per each payment request then the agency 24 can
indicate the payee 302 for each individual payment request 304. The
payee may be the worker 22, an equipment/service supplier (such as
an SSP), the provider PSP, or any other third party.
[0178] Referring to FIGS. 2 and 27, once the LMR UR rules DB 64
information has been inserted into the adjudication engine 38, in
response to the approved plan 206 (see FIG. 6), generation of bills
402 from the predictive payment requests 304 (see FIG. 25) can
begin. The bill generation process 400 applies logic through the
workflow engine 36 at a predetermined time/schedule on a daily
basis, for example, to retrieve predictive payment details
(corresponding to the payment requests 304 of the plans 206) from
the Bill Scheduling database 62. The predictive bill data of the
database 62 is reformatted by the workflow engine 40 and then
inserted into the bill adjudication queue 48, for eventual LMR bill
402 creation and submission into the adjudication engine 38 for
adjudication. The adjudication of these LMR bills 402 provides the
payment engine 40 with payment details, which are used to issue
payment by the system 10 to the providers PSP in response to the
predictive elements of the corresponding plan 206. The process 400
uses the parameters of the payment request(s) 304 within the plan
206 to determine what data to insert into the payment bill entity.
The process 400 also applies logic in order to determine the
required number of bills to be generated based on the payee
combinations for the predictive payment plan 206, for example
coordination of benefits (COB) that are part of the plan 206 as
well as direct payment to the worker 2 and SSPs if desired. The
bill generation process 400 can use standard fields and values,
such as the 837 EDI import process.
[0179] Referring to FIG. 27, the bill generation process 400 is run
on a predefined frequency in order to pick up from the database 62
and send bill payment requests 304 that run on user defined
anniversary dates, as well as being able to run on specific set
dates. The trigger for the bill generation will be the parameters
306, 308, 310, 312, 314, 316 in the predictive payment plan (see
FIG. 25). Accordingly, the automatic generation of the LMR bills
402 involves the coordinated effort between the workflow engine 40
and the contents of the IDB 26, as well as the procedures 70, 72,
74, 68 as discussed above (see FIG. 2).
[0180] Referring again to FIG. 27, the process 400: [0181] 1. uses
the system 10 through the workflow engine 40 to trigger 404 the
bill generation to start on a daily basis or other predefined
period; [0182] 2. the system 10 checks 406 the Predictive Payment
schema in database 62 of the IDB; [0183] 3. the system checks 408
each predictive payment plan stored in system 10 for an Active
status; [0184] 4. for each plan that is active the system 10 also
checks 408 to see that all payment requests 304 12 are Active;
[0185] 5. if any payment requests 304 are not active 410 the bill
generation process 400 does not use them for bill generation and
proceeds to the next 411 bill; [0186] 6. for each active plan with
active payment requests 304 the system 10 checks 412 to see what
date is contained in a Next Bill Generation Date column of the
scheduling data in the database 62; [0187] 7. if the date contained
in the Next Bill Generation Date column is equal/matches 414 to the
current date then the system 10 flags that for this plan and
payment requests 304 the system 10 must generate the bill 402;
[0188] 8. once the system 10 flags that the bill 402 is required
for this plan and payment requests 304 it moves 416 the date in the
Next Bill Generation Date column to a Last Bill Generation Date
column, hence updating 416 the bill generation frequency; [0189] 9.
next the system 10 looks at a Frequency parameter for that payment
request 304 and calculates what date the next bill 402 needs to be
generated on and inserts that date value into the Next Bill
Generation Date column; [0190] 10. the system checks 418 for other
bills 402 and steps 6-9 are repeated by the system 10 until it has
collected all of the payment requests 304 that require each of the
bills 402 to be generated for specific plans 206; [0191] 11. next
the system 10 evaluates if one or more bills 402 are required to be
generated that day/period for that plan by confirming 420 the
payment details in steps 12-15; [0192] 12. the system 10 checks an
All Payee flag for each potential bill 402; [0193] 13. if the All
Payee flag is set then the system 10 will skip to step 16; [0194]
14. if the All Payee flag is not set then the system 10 looks at a
payee id parameter, which denotes the identity for different
payees; [0195] 15. for each different payee id per payment request
304 for that plan the system 10 can create a different bill 402;
[0196] 16. once the system 10 has determined how many bills 402 are
required for one plan, it begins populating 422 the bill export
table 48 in the IDB 26 with the parameters stored in the predictive
payment schema of the bill scheduling database 62; [0197] 17. once
the system 10 has completed inserting all the bill 402 data into
the bill export table 48 in the IDB, the bill generation process is
completed and the query bills procedure 70 is used by the workflow
engine 40 to import the LMR bills 402 into the adjudication engine
38 for adjudication 424 and eventual bill 402 generation.
[0198] It should be noted that information on the
processing/payment history of the bills 402 is stored in the IDB
for subsequent access through the interfaces 12, 14. Further, when
the predictive payment plan 206 or one of the service codes 306
within the predictive payment plan has moved from suspend to
reactivate status, the system 10 determines the start and end date
of the suspension period and determines if during this time the
corresponding bill 402 was not generated. For example, an
activation date can be provided by the user to determine date range
for bill generation for the suspended period. Preferably, if no
activation period is supplied, the bill generation process 400 will
assume that the reactivation period will be the full suspension 28
period.
[0199] Although the invention has been described with reference to
certain specific embodiments, various modifications thereof will be
apparent to those skilled in the art without departing from the
spirit and scope of the invention as outlined in the claims
appended hereto.
* * * * *