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Proration of Health CARE Benfits

IP.com Disclosure Number: IPCOM000039557D
Original Publication Date: 1987-Jun-01
Included in the Prior Art Database: 2005-Feb-01
Document File: 4 page(s) / 44K

Publishing Venue

IBM

Related People

Sutherland, RW: AUTHOR [+2]

Abstract

Traditionally insurance proration, distributing medical costs among insurers and patients, has been done manually or by automated processes specifically developed for a particular line of insurance. Because of the number of differing insurance coverages, it is extremely difficult to provide a single program which is capable of processing complex insurance benefit information concerning a myriad of different insurance companies and coverages on a generalized computer system. The insurance proration features of the Patient Care System - Patient Accounting program gives a user a highly flexible set of insurance information and a generalized automated proration process. The proration feature is an iterative process of passing transactions (charges and credits) against the benefits associated with an account.

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Proration of Health CARE Benfits

Traditionally insurance proration, distributing medical costs among insurers and patients, has been done manually or by automated processes specifically developed for a particular line of insurance. Because of the number of differing insurance coverages, it is extremely difficult to provide a single program which is capable of processing complex insurance benefit information concerning a myriad of different insurance companies and coverages on a generalized computer system. The insurance proration features of the Patient Care System - Patient Accounting program gives a user a highly flexible set of insurance information and a generalized automated proration process. The proration feature is an iterative process of passing transactions (charges and credits) against the benefits associated with an account. It uses six types or levels of benefits grouped into two categories. The categories are: Limits and Deductibles. The table below shows the benefit types from the lowest to the highest level of inclusion. The category of a benefit determines which party, either patient or insurer, is responsible for a charge or is the recipient of a credit. The benefits within each category are processed in a particular order, from the most to the least inclusive, or from the Charge benefit which prorates only transactions with a specific service codes, to the Policy benefit which prorates any transaction. Within each benefit is the control information for determining which transactions it affects and how to divide the amount of the transaction. After all benefits on an account have been processed, the final prorated amounts are placed in the transaction as a record of this activity. Within the Patient Accounting program, coverage is organized into three categories. These categories differ from one another in their usage and the types of information kept on the data base. The categories are: Master, Regular and Regular/Master Plans. 1. A REGULAR PLAN describes the coverage for a specific carrier. It has all the types

of information shown above. A Regular Plan can be

assigned to a patient's account. 2. A MASTER PLAN describes generic coverage and is not related to a specific carrier. It has Basic, Plan and

Benefit information. Master Plans cannot be assigned

to an account, but are used by other plans as a common

source for benefits. 3. A REGULAR/MASTER PLAN describes coverage using the benefits described under a Master Plan. It has Basic,

Plan, Address and Missing Element information. This

type of plan can be assigned to an account. This arrangement gives the health care facility the flexibility to group common coverages for different carriers under a single Master Plan and yet produce claims addressed to specific third parties. The primary use of third party information is for the proration of charges and credits. The information in this data base is the source for the proration controls and is not changed by the pr...