Routing claims from automatic adjudication system to user interface

Routing claims from automatic adjudication system to user interface

A claim adjudication system including an automatic adjudication pipeline that uses pipeline rules to automatically adjudicate a claim associated with a benefit plan at one or more stages. The automatic adjudication pipeline can redirect the claim to a user interface for manual review when a pipeline...

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Bibliographische Detailangaben
Hauptverfasser: Chiv, Henning, Martinez-Ortuno, Sergio, Ross, Izac Benjamin Milstein, Eskin, Yulia, N'Gouan, Raphael, Ye, Xiaowen, Halpern-Manners, Nicholas, Tollinger, Irene Victoria, Horowitz, Erica Leigh, Bedingten, Thomas, Chang, Andrew, Grates, Heather, Ithal, Chetan Subramanya, Khalak, Asif, O'Leary, John George
Format: Patent
Sprache:eng
Schlagworte:
CALCULATING
COMPUTER SYSTEMS BASED ON SPECIFIC COMPUTATIONAL MODELS
COMPUTING
COUNTING
DATA PROCESSING SYSTEMS OR METHODS, SPECIALLY ADAPTED FORADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL, SUPERVISORYOR FORECASTING PURPOSES
PHYSICS
SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE,COMMERCIAL, FINANCIAL, MANAGERIAL, SUPERVISORY OR FORECASTINGPURPOSES, NOT OTHERWISE PROVIDED FOR
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Beschreibung
Zusammenfassung:A claim adjudication system including an automatic adjudication pipeline that uses pipeline rules to automatically adjudicate a claim associated with a benefit plan at one or more stages. The automatic adjudication pipeline can redirect the claim to a user interface for manual review when a pipeline rule associated with a manual review condition is triggered. The user interface can present information about the claim relevant to the manual review condition in an integrated format, including highlighting the reasons for the manual review. A user can evaluate the claim in the user interface and provide user input that addresses the manual review condition, and the claim can be routed back to the automatic adjudication pipeline. The user input can also be used as training data for machine learning to adjust pipeline rules that are used to automatically process claims and to redirect future claims for manual review.