EP1303825A1 - System and method for processing insurance claims - Google Patents
System and method for processing insurance claimsInfo
- Publication number
- EP1303825A1 EP1303825A1 EP01946676A EP01946676A EP1303825A1 EP 1303825 A1 EP1303825 A1 EP 1303825A1 EP 01946676 A EP01946676 A EP 01946676A EP 01946676 A EP01946676 A EP 01946676A EP 1303825 A1 EP1303825 A1 EP 1303825A1
- Authority
- EP
- European Patent Office
- Prior art keywords
- insurance
- help information
- help
- database
- processing
- Prior art date
- Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
- Withdrawn
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Classifications
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- G—PHYSICS
- G06—COMPUTING; CALCULATING OR COUNTING
- G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
- G06Q40/00—Finance; Insurance; Tax strategies; Processing of corporate or income taxes
- G06Q40/02—Banking, e.g. interest calculation or account maintenance
Definitions
- TITLE SYSTEM AND METHOD FOR PROCESSING INSURANCE CLAIMS
- the present invention generally relates to the field of insurance claims. More particularly, the present invention relates to a system and method for processing insurance claims using a graphical user interface.
- a knowledge-based claim-processing system includes an expert system which utilizes and builds a knowledge base to assist the user in decision making. It may allow the insurance companies to define new rules and/or use previously defined rules, in real-time.
- the business rules are generally written by industry experts to evaluate legal, medical, insurance conditions before arriving at a valuation of a claim.
- the user interface (such as a graphical user interface, or GUI) lacked flexibility and was inefficient.
- GUI graphical user interface
- the knowledge-based prior art claim processing system would then utilize the user provided inputs, i.e., collect data from the user to generate a claim report. This reduced the user's flexibility and usability. For example, the user was required to enter the requested/required information for each display, before being permitted to proceed to the next display.
- the user interface used in the prior art would not permit the user to easily go back to edit data that was entered in a previous display or to go forward to another display.
- the application In order to go back to a desired previous display, the application would automatically exit, re-launch, and then go through all the previous displays in sequence to arrive at the desired previous display.
- GUI graphical user interface
- the GUI It is, therefore, desirable to develop a new graphical user interface to improve usability and flexibility of a knowledge-based claims processing system. It is desirable for the GUI to provide the user with a road map of all the steps involved with the data collection process. It is also desirable for the GUI to provide full control to the user to select any display screen to enter required data. Thus, the GUI should be of a flexible design to allow the user to select display screens freely, based on user requirements. Furthermore, it is also desirable for the user to be able to edit inputs which were previously entered on previous display screens.
- the user may have special or unique requirement, which may required that the standard formulas be modified or customized to meet a specific application. For example, different zones or geographic areas in the United States may have different monetary values associated with trauma severity for the same type of injury.
- the hard-coding method to compute formulas, used in the previous approaches, may not easily permit the customization of the formulas in a cost and time effective manner.
- the messages display system and method should be of a flexible design to allow the user to freely select message text based on user requirements.
- the user may enter inputs on a display screen and step through a series of displays or screens to complete the data input process.
- the knowledge-based claim processing system may then utilize the user-provided inputs to generate a claim report.
- Help information in the form of documents such as manuals and guidebooks may be provided by the knowledge-based systems to help the user in completing the data input process.
- the help information may be provided in printed form or, in some systems, in electronic form.
- the volume and complexity of the supplied help information may make it difficult for the user to locate a portion or portions of the information pertinent to a current step or screen that the user is working on in the data input process.
- the user may enter inputs on a display screen and step through a series of displays or screens to complete the data input process. This process may be referred to as a consultation session.
- the knowledge-based claim processing system may then utilize the user- provided inputs to generate a consultation report.
- the consultation report may include, for example, an estimate of a value of an insurance claim.
- the user may enter inputs on a display screen and step through a series of displays or screens to complete the data input process. This process may be referred to as a consultation session.
- the knowledge-based claim processing system may then utilize the user- provided inputs to generate a consultation report.
- the consultation report may include, for example, an estimate of a value of an insurance claim.
- the present invention provides various embodiments of a system and method for processing and estimating a value of an insurance claim using a table of contents.
- the processing of the insurance claim my be initiated by initiating a first step, wherein the processing of the insurance claim includes a plurality of steps.
- the steps may include screens displayed on a display device coupled to a computer system.
- the insurance claim may include a bodily injury claim, and processing the insurance claim to estimate the value of the insurance claim may include processing the bodily injury claim to estimate a bodily injury general damages value.
- the steps may include steps for entry of information relevant to the estimate of the value of the insurance claim.
- the information may include, for example, bodily injury treatment information and/or bodily injury damages information.
- One or more of the steps in the processing of the insurance claim may be proceeded through to arrive at an intermediary step.
- the intermediary step is any step between the first and final steps in the plurality of steps of processing the insurance claim. Proceeding through the one or more of the steps in the processing of the insurance claim may include entering information relevant to the estimate of the value of the insurance claim in the one or more of the steps. The entered information may be stored in a memory. The intermediary step may then be displayed. A table of contents may be displayed upon the entry of an appropriate command by the user, wherein the table of contents includes an ordered list of the steps associated with the processing of the insurance claim, and wherein the ordered list of steps comprises the first step, the intermediary step, and any steps in between the first step and the intermediary step.
- the ordered list of steps may be dynamically modifiable in response to the entry of information in a step.
- steps may be added to or deleted from said dynamically modifiable ordered list of steps in response to the entry of information.
- the user may be permitted to select one of the steps from the ordered list of steps associated with the processing of the insurance claim in the table of contents.
- the selected step may then be displayed in response to the user selecting the selected step in the table of contents.
- the entered information in the selected step may be modified after selecting the step in the table of contents.
- the modified information may be stored.
- the intermediary step may be redisplayed upon entry of an appropriate command by the user.
- the user may go back to the previously displayed step, either through the table of contents or through entry of a suitable "back" command.
- the processing of the insurance claim may be continued after redisplaying the intermediary step by permitting the user to enter additional information relevant to the estimate of the value of the insurance claim.
- the ordered list of steps in the table of contents may include a final step.
- the final step may be selected at any time from the table of contents.
- the final step may include a consultation report concerning an estimate of the value of the insurance claim.
- the consultation report may include information related to the estimate of the value of the insurance claim, wherein the estimate may be calculated based on information entered in the first step and in any steps in between the first step and the intermediary step.
- all or substantially all of the steps associated with using the table of contents may be executed within a single session of an application program executing on a computer system. Therefore, the user of the system need not exit the system and restart from the beginning in order to go back to a previously encountered step.
- the present invention also provides various embodiments of a system and method for identifying one or more contributing factors relevant to an estimate of a value of an insurance claim.
- one or more insurance codes which are relevant to the value of the insurance claim may be specified in an insurance claims processing program executable on a computer system. Each insurance code may be considered a contributing factor to the estimated value of the insurance claim.
- These insurance codes may be entered by a user during a consultation session in which a claimant reports his or her injuries and/or treatments for a particular insurance claim.
- a claim number for the insurance claim may be specified, and the one or more insurance codes may be associated with the claim number.
- the insurance codes may include one or more injury codes, wherein each injury code specifies a bodily injury incurred by the claimant.
- the insurance codes may include one or more treatment codes, wherein each treatment code specifies a treatment for at least one of the bodily injuries incurred by the claimant.
- One or more contributing factor values may be determined. Each of the contributing factor values corresponds to one of the insurance codes, and each of the contributing factor values measures an estimated impact of the corresponding insurance code on the value of the insurance claim.
- the insurance claim may include a bodily injury claim, and the contributing factor values may be relevant to an estimate of a bodily injury general damages value of the bodily injury claim.
- Each of the one or more contributing factor values may include a numeric value.
- determining the one or more contributing factor values may include calculating the one or more contributing factor values as a function of one or more business rules.
- a rules engine or other expert system may be configured to calculate dynamically the amount that each insurance code adds to or subtracts from the estimate of the value of the insurance claim. This amount contributed by one insurance code may be dependent on the amounts contributed by other specified insurance codes.
- the expert system may be developed using the PLATINUM AionTM rule-based development environment available from Computer Associates International, Inc.
- Each of the one or more insurance codes and the corresponding contributing factor values may be stored in a table.
- the table may include one or more rows, wherein each row of the table includes one of the insurance codes and the corresponding contributing factor value.
- the table may be implemented as a table in a relational database.
- the table may be implemented in accordance with object- oriented techniques of software design.
- the table may be sorted by the contributing factor values to generate a sorted table of contributing factor values and corresponding insurance codes.
- the table may be sorted by contributing factor value in ascending or descending order.
- a set of contributing factors from the sorted table which meet one or more selection criteria may be identified and reported.
- the set of contributing factors may be included in a consultation report which may be printed and/or displayed on a display device.
- the selection criteria may include a selection of the largest positive of the one or more contributing factor values up to a certain quantity, such as five. Therefore, identifying and reporting the set of contributing factors from the sorted table may include identifying and reporting a sorted set of the largest contributing factor values up to the certain quantity. In one embodiment, each contributing factor value in the sorted set of the largest positive contributing factor values adds to the estimate of the value of the insurance claim.
- the selection criteria may include the largest negative of the one or more contributing factor values up to a certain quantity, such as five.
- identifying and reporting the set of contributing factors from the sorted table may include identifying and reporting a sorted set of the largest negative contributing factor values up to the certain quantity. Each contributing factor value in the sorted set of the largest negative contributing factor values subtracts from the estimate of the value of the insurance claim.
- the present invention provides various embodiments of a system and method for externalization of formulas to assess bodily injury general damages.
- an insurance company may use an expert system to develop a knowledge base in the form of business rules and formulas to process insurance claims.
- the formulas may be invoked by the business rules to calculate trauma severity values associated with a bodily injury insurance claim.
- a rules engine may execute the business rules and formulas.
- the database which is external to the rules engine, may store all business rules, formulas, program instructions, data, tables, objects, etc. associated with the processing of insurance claims.
- the database may be an object oriented or a relational database.
- the database may include a plurality of knowledge bases often storing knowledge data in the form of tables. The data stored in the knowledge bases may also be in the form of objects.
- the user may create a formulas data table, which is an embodiment of a knowledge base and which includes data necessary to transform the formula data to formulas.
- a formula type may include a mathematical function operating on one or more inputs to compute one or more outputs.
- new formula types may be created and added to existing formula types to customize the formulas.
- the transformation program reads each row of the formula data table and creates a static instance of an object in the formula class in a separate knowledge base named formulas.
- Business rules may invoke the static instance of formula using the calculate method.
- the calculate method gathers all of the static instances with a specified FormulalD along with a sequence number.
- the calculate method interprets the operations and controls how the formula is executed.
- the resulting output value may be used to calculate the trauma severity value.
- the present invention provides various embodiments of a system and method for externalization of rules to assess bodily injury general damages.
- an insurance company may use an expert system to develop a knowledge base in the form of business rules to process insurance claims.
- a rules engine operable to execute the business rules may assist an insurance claims adjuster in assessing damages associated with bodily injury claims.
- the database which is external to the rules engine, may store all business rules, program instructions, data, tables, objects, etc. associated with the processing of insurance claims.
- the database may be an object oriented or a relational database.
- the database may include a plurality of knowledge bases often stored in the form of tables.
- the user may create a rules data table, which is an embodiment of a knowledge base and which includes data necessary to transform the data to business rules, based on a rule syntax structure specified in the template table.
- a rule style or a rule syntax structure includes a premise and one or more resulting actions.
- the entire set of business rules created to process insurance claims may be classified into a plurality of rule styles.
- new rule styles may be created and added to existing rule styles to customize the business rules.
- the transformation method orchestrates the combining of the data from the rules data table and the rule syntax structure specified in the template table and line text table.
- Each row of the rules data table may be read at a time.
- Data stored in each column of the rules data table may be used to transform or create the business rules.
- entries for rules style may be used as a key to read a matching record in the template table.
- the matching record in the template table may specify the specific rule syntax structure.
- the new business rule may be saved in an associated knowledge base.
- the present invention provides various embodiments of an improved method and system to display messages, while processing insurance claims, using a messages table.
- the messages associated with the processing of insurance claims are primarily used to obtain inputs from the user of the claims processing computer system.
- Messages which are typically displayed on a display screen, may include questions, answers, errors, warnings, and other text used with interactive claims processing.
- the user defines the entries in the messages table and stores them in a database.
- the messages are stored as message codes along with a corresponding message text in a messages table.
- the database which includes the messages table is the repository and the lookup system for the message codes and the corresponding message texts.
- Each message code has a corresponding customizable message text, which may be specified at installation time.
- the application program may request a display of a specific message by providing its message code.
- the GetMessageText method of the Message object may be invoked, along with providing the values for MsgSectionln and MsgCodeln arguments associated with the GetMessageText method.
- GetMessageText method on execution, accesses the messages table and obtains the corresponding message text which is then passed on to the requesting application program.
- the application program thus, remains unaffected to changes in corresponding customizable message texts.
- the present invention provides various embodiments of a mechanism for providing context-sensitive help and the ability to interactively search a help database in insurance claims processing systems.
- One or more index tables may be provided for locating terms and codes for context-sensitive help and for interactively searching for terms in the help database.
- Each entry in the one or more index tables may represent an occurrence of a term or code in a document included in the help database for the insurance claims processing system.
- Examples of documents that may be included in the help database for the insurance claims processing system include, but are not limited to: medical journals, textbooks and/or manuals, insurance claims processing manuals or guidebooks, medical glossaries and/or dictionaries, and documents including context sensitive help entries for the insurance claims processing steps, and elements of the steps, in the insurance claims processing system.
- An entry in the index table may include an object ID.
- the object ID may indicate a unique entry in a help information table in the help database.
- An entry in the index table may also include a term field.
- a term field may include a term located in the one or more documents in the help database, or alternatively a term field may include a code representing a step or an element in a step in the insurance claims processing system.
- a "term" may include one or more words, abbreviations, numerical values, or other types of alphanumeric strings that may appear in documents in an insurance claims processing help database.
- An entry in the index table may also include a Soundex field for locating words that are misspelled.
- the entries in the index table may include a relevance value for the occurrence of the term in the help database.
- a relevance value may be defined as an estimated measure of the significance of the occurrence of a term to the text object (header or text section) in which the occurrence is located.
- the relevance values for the entries in the index table may be calculated and stored in the index table prior to a user accessing the help database.
- the relevance value for an entry in the index table may be calculated dynamically when the entry is identified as an occurrence of a search term or of a step or step element code in context-sensitive help.
- relevance values for the entries in the index table may be calculated using the position of the term in the text object (header or text section), the number of words in the term, the number of words in the text object, and the type of text object for the entry (header or text section?).
- occurrences in headers may be considered generally more relevant than occurrences in text sections, and therefore a different mechanism may be used to calculate the relevance of occurrences in headers than the mechanism used to calculate the relevance of occurrences in text sections.
- the help information database may include one or more header tables and one or more text tables.
- a header table may include a plurality of records, also referred to as entries, with one entry for each header element from the one or more documents to be included in the help database for the insurance claims processing system. Each entry may comprise a plurality of fields or elements.
- An index table may include a plurality of entries, with one entry for each text section from the one or more documents to be included in the help database for the insurance claims processing system. Each entry may comprise a plurality of fields or elements. In one embodiment, the fields may be substantially similar to the fields in embodiments of the header table.
- An entry in a header or text table may include an object identifier (object ID).
- the object ED for the entry may be unique in the help database.
- the object ID may include information that may be used to identify the document including the entry, and the location in the document of the entry.
- an entry may include the object identifier of the parent entry for the entry.
- An entry in a header or text table may also include fields with information on the location in the document of the entry.
- An entry in a header or text table may also include alphanumeric text from the document. When the entry is located during context sensitive help or a search, the alphanumeric text may be read from the entry and displayed on the display screen for a user to view. Alternatively, the entry may not store the actual text, but may instead include information for locating the text for the entry in the document. In this case, when the entry is located, the actual text for the entry may be read from the document itself and displayed for the user.
- a user may initiate processing of an insurance claim in the insurance claims processing system.
- the insurance claims processing may begin at a first processing step, and may continue through a number of processing steps until the insurance claim processing is complete.
- a next processing step may be determined by user input at a current processing step, or alternatively may be predetermined (i.e. step B always follows step A).
- a processing step may be divided into one or more screens or pages, wherein one screen or page at a time is displayed on display screen.
- the insurance claims processing system may enter a processing step and display a page for the processing step.
- the context-sensitive help for the step may be automatically invoked when entering the step.
- the user may interactively invoke context-sensitive help once the page is displayed.
- Context-sensitive help for each processing step may be unique, although some content may appear in the context-sensitive help for two or more processing steps.
- Context-sensitive help may also be unique for each of the one or more pages within a processing step.
- the page for the processing step may be displayed with the context-sensitive help for the page.
- a display page may be divided into two or more panes, the context-sensitive help may be displayed in one or more panes on the page, and the processing step contents may appear in one or more panes on the page.
- each step or each page in a step in the insurance claims processing system may have a unique code, which may be referred to as a page ID.
- a page may also include one or more step elements that have associated codes.
- step elements may include interface items that a user of the system interacts with in performing the step.
- the step elements on the page may include system- supplied "answers" to questions posed to the user during the claims processing.
- the step elements may include lists of injury codes selectable by the user.
- the step elements may include lists of treatments for injuries selectable by the user.
- the insurance claims processing system may search one or more index tables for entries including the page ID. The index table may also be searched for entries including the codes from one or more elements of the page.
- the search may result in the insurance claims processing system locating one or more entries in the one or more index tables. In one embodiment, there will be at least one entry located for the page ID in the one or more index tables. In one embodiment, if elements of the page have an associated code, there will be at least one entry located for each code in the one or more index tables. In one embodiment, each entry in the one or more index tables may indicate an occurrence in the one or more documents included in the help database for the insurance claims processing system of the page ID, code, or term included in the index table entry.
- the insurance claims processing system may then locate entries in the one or more help tables using information from the entries located in the one or more index tables for the page ED and any elements of the page.
- the one or more help tables may be searched for occurrences of the object ID from each located entry in the index table.
- the insurance claims processing system may then rank the located help table entries by relevance value.
- the located help table entries may be ranked from highest relevance to lowest relevance.
- the located help table entries may be listed without being ranked by relevance.
- any entries found for a page code may be displayed at the top of the list regardless of the relevance ranking of the entry. Entries for other codes in the page may then be ranked below the page code entry or entries in order of relevance.
- located entries may be first ranked on the number of search terms the entries include. Entries that include more search terms may be ranked higher than entries with fewer search terms. The entries within the ranking categories may then be ranked by relevance within the category. The insurance claims processing system may then display information from the located help table entries.
- the entries may be displayed in the order of relevance of the entries.
- the help table entries may include portions of text from one or more documents related to insurance claims processing. Some help table entries may include section headers from the one or more documents. Some help table entries may include text from the bodies of sections of the one or more documents. Some help entries may include glossary information from the one or more documents. Other entries may include text from other portions of the one or more documents.
- the relevance value may also be displayed.
- the insurance claims processing system may also display information describing the location of the displayed portions of text in the one or more documents. This information may allow the user to look up (electronically or manually) located occurrences in the one or more documents.
- a search interface may be provided to the user of the insurance claims processing system. The user may enter in the search interface one or more terms to be searched for in the help database for the insurance claims processing system. The user may then initiate the search for the one or more terms.
- the insurance claims processing system may then search the one or more index tables for entries including at least one of the one or more terms.
- the insurance claims processing system may locate one or more entries in the one or more index tables that include at least one of the one or more terms.
- the located entries in the index table may be used to locate help entries in the one or more help tables that include at least one of the one or more terms.
- the one or more help tables may be searched for occurrences of the object ID from each of the located entries.
- the located help table entries may be ranked by relevance.
- the located help table entries may be ranked from highest relevance to lowest relevance.
- located entries may be first ranked on the number of search terms the entries include. Entries that include more search terms may be ranked higher than entries with fewer search terms. The entries within the ranking categories may then be ranked by relevance within the category. Thus, entries with lower relevance, but more search terms, may appear higher in the overall ranking than entries with higher relevance, but fewer search terms.
- the insurance claims processing system may then display information from the located help table entries.
- the entries may be displayed in the order of relevance of the entries.
- the help table entries may include portions of text from one or more documents related to insurance claims processing. Some help table entries may include section headers from the one or more documents. Some help table entries may include text from the bodies of sections of the one or more documents. Some help entries may include glossary information from the one or more documents. Other entries may include text from other portions of the one or more documents. In one embodiment, the relevance value may also be displayed.
- the insurance claims processing system may also display information describing the location of the displayed portions of text in the one or more documents. This information may allow the user to look up (electronically or manually) located occurrences in the one or more documents.
- the present invention provides various embodiments of a mechanism for providing context-sensitive help and the ability to interactively search a help database in insurance claims processing systems.
- One or more index tables may be provided for locating terms and codes for context-sensitive help and for interactively searching for terms in the help database.
- Each entry in the one or more index tables may represent an occurrence of a term or code in a document included in the help database for the insurance claims processing system.
- Examples of documents that may be included in the help database for the insurance claims processing system include, but are not limited to: medical journals, textbooks and/or manuals, insurance claims processing manuals or guidebooks, medical glossaries and/or dictionaries, and documents including context sensitive help entries for the insurance claims processing steps, and elements of the steps, in the insurance claims processing system.
- An entry in the index table may include an object ID.
- the object ID may indicate a unique entry in a help information table in the help database.
- An entry in the index table may also include a term field.
- a term field may include a term located in the one or more documents in the help database, or alternatively a term field may include a code representing a step or an element in a step in the insurance claims processing system.
- a "term" may include one or more words, abbreviations, numerical values, or other types of alphanumeric strings that may appear in documents in an insurance claims processing help database.
- An entry in the index table may also include a Soundex field for locating words that are misspelled.
- the entries in the index table may include a relevance value for the occurrence of the term in the help database.
- the relevance of an occurrence of a term may be defined as the relevance of the term to the text object (header or text section) in which the occurrence is located.
- the help database may include one or more header tables and one or more text tables.
- a header table may include a plurality of records, also referred to as entries, with one entry for each header element from the one or more documents to be included in the help database for the insurance claims processing system. Each entry may comprise a plurality of fields or elements.
- An index table may include a plurality of entries, with one entry for each text section from the one or more documents to be included in the help database for the insurance claims processing system. Each entry may comprise a plurality of fields or elements. In one embodiment, the fields may be substantially similar to the fields in embodiments of the header table.
- An entry in a header or text table may include an object identifier (object ID). In one embodiment, the object ID for the entry may be unique in the help database.
- the object ID may include information that may be used to identify the document including the entry, and the location in the document of the entry.
- an entry may include the object identifier of the parent entry for the entry.
- An entry in a header or text table may also include fields with information on the location in the document of the entry.
- An entry in a header or text table may also include alphanumeric text from the document. When the entry is located during context sensitive help or a search, the alphanumeric text may be read from the entry and displayed on the display screen for a user to view. Alternatively, the entry may not store the actual text, but may instead include information for locating the text for the entry in the document.
- a user may initiate processing of an insurance claim in the insurance claims processing system.
- the insurance claims processing may begin at a first processing step, and may continue through a number of processing steps until the insurance claim processing is complete.
- a next processing step may be determined by user input at a current processing step, or alternatively may be predetermined (i.e. step B always follows step A).
- a processing step may be divided into one or more screens or pages, wherein one screen or page at a time is displayed on display screen.
- the insurance claims processing system may enter a processing step and display a page for the processing step.
- the context-sensitive help for the step may be automatically invoked when entering the step.
- Context-sensitive help for each processing step may be unique, although some content may appear in the context-sensitive help for two or more processing steps. Context-sensitive help may also be unique for each of the one or more pages within a processing step.
- the page for the processing step may be displayed with the context-sensitive help for the page.
- a display page may be divided into two or more panes, the context-sensitive help may be displayed in one or more panes on the page, and the processing step contents may appear in one or more panes on the page.
- each step or each page in a step in the insurance claims processing system may have a unique code, which may be referred to as a page ID.
- a page may also include one or more step elements that have associated codes.
- step elements may include interface items that a user of the system interacts with in performing the step.
- the step elements on the page may include system- supplied "answers" to questions posed to the user during the claims processing.
- the step elements may include lists of injury codes selectable by the user.
- the step elements may include lists of treatments for injuries selectable by the user.
- the insurance claims processing system may search one or more index tables for entries including the page ID.
- the index table may also be searched for entries including the codes from one or more elements of the page.
- the search may result in the insurance claims processing system locating one or more entries in the one or more index tables.
- if elements of the page have an associated code there will be at least one entry located for each code in the one or more index tables.
- each entry in the one or more index tables may indicate an occurrence in the one or more documents included in the help database for the insurance claims processing system of the page ID, code, or term included in the index table entry.
- the insurance claims processing system may then locate entries in the one or more help tables using information from the entries located in the one or more index tables for the page ID and any elements of the page.
- the one or more help tables may be searched for occurrences of the object ID from each located entry in the index table.
- the insurance claims processing system may then rank the located help table entries by relevance value.
- the located help table entries may be ranked from highest relevance to lowest relevance.
- the located help table entries may be listed without being ranked by relevance.
- any entries found for a page code may be displayed at the top of the list regardless of the relevance ranking of the entry. Entries for other codes in the page may then be ranked below the page code entry or entries in order of relevance.
- the insurance claims processing system may then display information from the located help table entries.
- the entries may be displayed in the order of relevance of the entries.
- the help table entries may include portions of text from one or more documents related to insurance claims processing. Some help table entries may include section headers from the one or more documents. Some help table entries may include text from the bodies of sections of the one or more documents. Some help entries may include glossary information from the one or more documents. Other entries may include text from other portions of the one or more documents. In one embodiment, the relevance value may also be displayed.
- the insurance claims processing system may also display information describing the location of the displayed portions of text in the one or more documents. This information may allow the user to look up (electronically or manually) located occurrences in the one or more documents.
- a search interface may be provided to the user of the insurance claims processing system.
- the user may enter in the search interface one or more terms to be searched for in the help database for the insurance claims processing system.
- the user may then initiate the search for the one or more terms.
- the insurance claims processing system may then search the one or more index tables for entries including at least one of the one or more terms.
- the insurance claims processing system may locate one or more entries in the one or more index tables that include at least one of the one or more terms.
- the located entries in the index table may be used to locate help entries in the one or more help tables that include at least one of the one or more terms.
- the one or more help tables may be searched for occurrences of the object ID from each of the located entries.
- the located help table entries may be ranked by relevance.
- the located help table entries may be ranked from highest relevance to lowest relevance.
- located entries may be first ranked on the number of search terms the entries include. Entries that include more search terms may be ranked higher than entries with fewer search terms. The entries within the ranking categories may then be ranked by relevance within the category. Thus, entries with lower relevance, but more search terms, may appear higher in the overall ranking than entries with higher relevance, but fewer search terms.
- the insurance claims processing system may then display information from the located help table entries.
- the entries may be displayed in the order of relevance of the entries.
- the help table entries may include portions of text from one or more documents related to insurance claims processing. Some help table entries may include section headers from the one or more documents. Some help table entries may include text from the bodies of sections of the one or more documents. Some help entries may include glossary information from the one or more documents. Other entries may include text from other portions of the one or more documents. In one embodiment, the relevance value may also be displayed.
- the insurance claims processing system may also display information describing the location of the displayed portions of text in the one or more documents. This information may allow the user to look up (electronically or manually) located occurrences in the one or more documents.
- the present invention provides various embodiments of a mechanism for providing context-sensitive help and the ability to interactively search a help database in insurance claims processing systems.
- One or more index tables may be provided for locating terms and codes for context-sensitive help and for interactively searching for terms in the help database.
- Each entry in the one or more index tables may represent an occurrence of a term or code in a document included in the help database for the insurance claims processing system.
- Examples of documents that may be included in the help database for the insurance claims processing system include, but are not limited to: medical journals, textbooks and/or manuals, insurance claims processing manuals or guidebooks, medical glossaries and/or dictionaries, and documents including context sensitive help entries for the insurance claims processing steps, and elements of the steps, in the insurance claims processing system.
- An entry in the index table may include an object ID.
- the object ID may indicate a unique entry in a help information table in the help database.
- An entry in the index table may also include a term field.
- a term field may include a term located in the one or more documents in the help database, or alternatively a term field may include a code representing a step or an element in a step in the insurance claims processing system.
- a "term" may include one or more words, abbreviations, numerical values, or other types of alphanumeric strings that may appear in documents in an insurance claims processing help database.
- An entry in the index table may also include a Soundex field for locating words that are misspelled.
- the entries in the index table may include a relevance value for the occurrence of the term in the help database.
- the relevance of an occurrence of a term may be defined as the relevance of the term to the text object (header or text section) in which the occurrence is located.
- the help information database may include one or more header tables and one or more text tables.
- a header table may include a plurality of records, also referred to as entries, with one entry for each header element from the one or more documents to be included in the help database for the insurance claims processing system. Each entry may comprise a plurality of fields or elements.
- An index table may include a plurality of entries, with one entry for each text section from the one or more documents to be included in the help database for the insurance claims processing system. Each entry may comprise a plurality of fields or elements. In one embodiment, the fields may be substantially similar to the fields in embodiments of the header table.
- An entry in a header or text table may include an object identifier (object ID).
- the object ID for the entry may be unique in the help database.
- the object ID may include information that may be used to identify the document including the entry, and the location in the document of the entry.
- an entry may include the object identifier of the parent entry for the entry.
- An entry in a header or text table may also include fields with information on the location in the document of the entry.
- An entry in a header or text table may also include alphanumeric text from the document. When the entry is located during context sensitive help or a search, the alphanumeric text may be read from the entry and displayed on the display screen for a user to view. Alternatively, the entry may not store the actual text, but may instead include information for locating the text for the entry in the document. In this case, when the entry is located, the actual text for the entry may be read from the document itself and displayed for the user.
- a user may initiate processing of an insurance claim in the insurance claims processing system.
- the insurance claims processing may begin at a first processing step, and may continue through a number of processing steps until the insurance claim processing is complete.
- a next processing step may be determined by user input at a current processing step, or alternatively may be predetermined (i.e. step B always follows step A).
- a processing step may be divided into one or more screens or pages, wherein one screen or page at a time is displayed on display screen.
- the insurance claims processing system may enter a processing step and display a page for the processing step.
- the context-sensitive help for the step may be automatically invoked when entering the step.
- the user may interactively invoke context-sensitive help once the page is displayed.
- Context-sensitive help for each processing step may be unique, although some content may appear in the context-sensitive help for two or more processing steps.
- Context-sensitive help may also be unique for each of the one or more pages within a processing step.
- the page for the processing step may be displayed with the context-sensitive help for the page.
- a display page may be divided into two or more panes, the context-sensitive help may be displayed in one or more panes on the page, and the processing step contents may appear in one or more panes on the page.
- each step or each page in a step in the insurance claims processing system may have a unique code, which may be referred to as a page ID.
- a page may also include one or more step elements that have associated codes.
- step elements may include interface items that a user of the system interacts with in performing the step.
- the step elements on the page may include system- supplied "answers" to questions posed to the user during the claims processing.
- the step elements may include lists of injury codes selectable by the user.
- the step elements may include lists of treatments for injuries selectable by the user.
- the insurance claims processing system may search one or more index tables for entries including the page ID. The index table may also be searched for entries including the codes from one or more elements of the page.
- the search may result in the insurance claims processing system locating one or more entries in the one or more index tables. In one embodiment, there will be at least one entry located for the page ID in the one or more index tables. In one embodiment, if elements of the page have an associated code, there will be at least one entry located for each code in the one or more index tables. In one embodiment, each entry in the one or more index tables may indicate an occurrence in the one or more documents included in the help database for the insurance claims processing system of the page ID, code, or term included in the index table entry.
- the insurance claims processing system may then locate entries in the one or more help tables using information from the entries located in the one or more index tables for the page ID and any elements of the page.
- the one or more help tables may be searched for occurrences of the object ID from each located entry in the index table.
- the insurance claims processing system may then rank the located help table entries by relevance value.
- the located help table entries may be ranked from highest relevance to lowest relevance.
- the located help table entries may be listed without being ranked by relevance.
- any entries found for a page code may be displayed at the top of the list regardless of the relevance ranking of the entry. Entries for other codes in the page may then be ranked below the page code entry or entries in order of relevance.
- the insurance claims processing system may then display information from the located help table entries.
- the entries may be displayed in the order of relevance of the entries.
- the help table entries may include portions of text from one or more documents related to insurance claims processing. Some help table entries may include section headers from the one or more documents. Some help table entries may include text from the bodies of sections of the one or more documents. Some help entries may include glossary information from the one or more documents. Other entries may include text from other portions of the one or more documents. In one embodiment, the relevance value may also be displayed.
- the insurance claims processing system may also display information describing the location of the displayed portions of text in the one or more documents. This information may allow the user to look up (electronically or manually) located occurrences in the one or more documents.
- a search interface may be provided to the user of the insurance claims processing system.
- the user may enter in the search interface one or more terms to be searched for in the help database for the insurance claims processing system.
- the user may then initiate the search for the one or more terms.
- the insurance claims processing system may then search the one or more index tables for entries including at least one of the one or more terms.
- the insurance claims processing system may locate one or more entries in the one or more index tables that include at least one of the one or more terms.
- the located entries in the index table may be used to locate help entries in the one or more help tables that include at least one of the one or more terms.
- the one or more help tables may be searched for occurrences of the object ID from each of the located entries.
- the located help table entries may be ranked by relevance.
- the located help table entries may be ranked from highest relevance to lowest relevance.
- located entries may be first ranked on the number of search terms the entries include. Entries that include more search terms may be ranked higher than entries with fewer search terms. The entries within the ranking categories may then be ranked by relevance within the category. Thus, entries with lower relevance, but more search terms, may appear higher in the overall ranking than entries with higher relevance, but fewer search terms.
- the insurance claims processing system may then display information from the located help table entries.
- the entries may be displayed in the order of relevance of the entries.
- the help table entries may include portions of text from one or more documents related to insurance claims processing. Some help table entries may include section headers from the one or more documents. Some help table entries may include text from the bodies of sections of the one or more documents. Some help entries may include glossary information from the one or more documents. Other entries may include text from other portions of the one or more documents. In one embodiment, the relevance value may also be displayed.
- the insurance claims processing system may also display information describing the location of the displayed portions of text in the one or more documents. This information may allow the user to look up (electronically or manually) located occurrences in the one or more documents.
- An interface item or items may be provided to the user for hiding or showing one or more panes displaying portions of the search results or context-sensitive help.
- the interface items may be items displayed graphically on the screen (for example, icons) and may be selectable using input output devices such as a mouse, joystick, or arrow keys on a keyboard.
- Interface items may also be keyboard selections such as function keys or key combinations.
- the insurance claim processing system may include a rules engine and a web server which is coupled to the rules engine.
- the rules engine may be configured to generate a plurality of insurance claim assessment questions.
- the insurance claim assessment questions may include bodily injury claim assessment questions.
- the web server may be configured to generate a plurality of web pages comprising the insurance claim assessment questions.
- the insurance claim processing system may further include a web browser which is configured to receive the plurality of web pages comprising the insurance claim assessment questions from the web server. The web browser may then be configured to display the plurality of web pages comprising the insurance claim assessment questions.
- the web browser may then be configured to receive insurance claim assessment data entered by a user in response to the insurance claim assessment questions during an insurance claim consultation session and send the insurance claim assessment data to the web server.
- the web server is further configured to receive the insurance claim assessment data from the web browser and send the insurance claim assessment data to the rules engine.
- the rules engine may be further configured to estimate a value of an insurance claim as a function of the insurance claim assessment data.
- the insurance claim may include a bodily injury insurance claim, and the insurance claim assessment data may include one or more bodily injuries and one or more treatments.
- the rules engine may be further configured to send the estimate of the value of the insurance claim to the web browser through the web server.
- the web browser may be further configured to display the estimate of the value of the insurance claim received from the rules engine through the web server.
- the insurance claim processing system may further include adapter software which is configured to enable communication between the rules engine and the web server.
- the adapter software may include one or more component interfaces such as COM interfaces.
- the adapter software may
- the web server and web browser are located on separate computer systems which are communicatively coupled through a network. In another embodiment, the web server and web browser may be located and executed on a single computer system.
- the insurance claim processing system may further include a plurality of web browsers corresponding respectively to a plurality of users.
- Each of the web browsers may be configured to receive one or more of the plurality of web pages comprising the insurance claim assessment questions from the web server, display the received web pages comprising the insurance claim assessment questions, receive insurance claim assessment data entered by one of a plurality of users in response to the insurance claim assessment questions during one of a plurality of insurance claim consultation sessions, and send the insurance claim assessment data to the web server.
- a method for developing a web-enabled insurance claims processing system may include providing a rules engine.
- the rules engine maybe configured to estimate a value of an insurance claim as a function of insurance claim assessment data entered by a user in response to insurance claim assessment questions.
- the method may further include providing a web server which is configured to generate a plurality of web pages which are viewable by a web browser.
- the method may further include wrapping the rules engine with a component interface in accordance with a component architecture specification.
- the component interface may include one or more definitions of methods of communication between the rules engine and the web server, wherein the methods of communication are operable to transmit the insurance claim assessment data from the web server to the rules engine and operable to transmit the insurance claim assessment questions from the rules engine to the web server.
- the insurance claim assessment data may include one or more bodily injuries and one or more treatments of the bodily injuries.
- the component architecture specification may include a Component Object Model (COM) specification.
- a first page of insurance claim assessment data may be displayed in a browser program executing on a computer system.
- the browser program may include a web browser program which is operable to read and display web pages.
- the computer system which executes the browser program may include a client computer system which is communicatively coupled to a server computer system.
- the server computer system may be operable to generate and send a plurality of pages of insurance claim assessment data to the client computer system.
- the first page may include one or more specialized navigation commands
- the browser program may include one or more standard navigation commands.
- the specialized navigation commands and the standard navigation commands may be displayed in the browser.
- the specialized navigation commands may include specialized navigation buttons in a graphical user interface (GUI), and selecting one of the specialized navigation commands comprises pushing one of the specialized navigation buttons.
- the specialized navigation commands may include a back command and a reset command.
- the specialized back command may be operable to redisplay a previous page of insurance claim assessment data.
- the standard navigation commands may include standard navigation buttons in a GUI, and selecting one of the standard navigation commands may include pushing one of the standard navigation buttons.
- the standard navigation commands may comprise a forward command and a back command.
- the standard back command may be operable to redisplay a previous web page, whether or not the previous web page includes insurance claim assessment data.
- One of the specialized navigation commands such as a forward command, may be selected to advance to a second page of insurance claim assessment data.
- the second page of insurance claim assessment data including the specialized navigation commands, may be displayed in the browser.
- one of the standard navigation commands may be selected to move back to the first page of insurance claim assessment data.
- the first page of insurance claim assessment data may then be redisplayed.
- the user may attempt to perform an insurance claim assessment task on the redisplayed first page of insurance claim assessment data. For example, the user may attempt to save a status of an insurance claim consultation.
- the insurance claim consultation may include an interactive determination of an estimate of a value of an insurance claim through the entry of insurance claim assessment data in response to insurance claim assessment questions.
- the insurance claim assessment task may also include, for example, entering new or modifying existing insurance claim assessment data.
- Insurance claim assessment data may include information relevant to an estimate of a value of an insurance claim, such as bodily injuries and treatments thereof.
- the insurance claim assessment data may include bodily injury claim assessment data, and the insurance claim assessment task may include a bodily injury claim assessment task.
- a navigation error may be generated as a result of the attempting to perform an insurance claim assessment task.
- a navigation error message may be generated and displayed as a result of the generating the navigation error.
- the navigation error message may include an instruction to select a reset command, wherein the reset command is one of the specialized navigation commands. The user may select the reset command after viewing the navigation error message.
- the second page of insurance claim assessment data may then be redisplayed. The user may then perform a second insurance claim assessment task on the redisplayed second page of insurance claim assessment data.
- the present invention provides various embodiments of an Internet-enabled method and system for processing insurance claims.
- the system may include an insurance claim processing server which may include a first CPU and a first memory coupled to the first CPU.
- the first memory may stores a first set of program instructions which are executable by the first CPU to estimate a value of an insurance claim as a function of insurance claim assessment data entered by a user during an insurance claim consultation session.
- the insurance claim may include a bodily injury claim, and the estimate of the value of the insurance claim may include an estimate of bodily injury general damages.
- the insurance claim assessment data may include one or more bodily injuries and one or more treatments of the bodily injuries.
- the first set of program instructions may include a rules engine and a web server.
- the first set of program instructions may be further executable by the first CPU to generate and send to a client computer system a plurality of web pages comprising insurance claim assessment questions.
- the system may also include a client computer system which may include a second CPU and a second memory coupled to the second CPU.
- the client computer system may be coupled to the insurance claim processing server through a network.
- the network may include the Internet, and the insurance claim processing server and the client computer system may therefore be operable to communicate over the network via TCP/IP.
- the second memory may store a second set of program instructions which are executable by the second CPU to receive the insurance claim assessment data entered by the user and send the insurance claim assessment data across the network to the insurance claim processing server.
- the second set of program instructions may include a web browser.
- the second set of program instructions may be further executable by the second CPU to display the web pages comprising the insurance claim assessment questions during the insurance claim consultation session.
- the system may include additional client computer systems such as a second client computer system including a third CPU and a third memory.
- the second client computer system may be coupled to the insurance claim processing server through the network.
- the third memory may store a third set of program instructions, such as a second web browser, which are executable by the third CPU to receive a second set of insurance claim assessment data entered by a second user.
- the third set of program instructions may be further executable to send the second set of insurance claim assessment data across the network to the insurance claim processing server.
- the first set of program instructions may be further executable to estimate a value of a second insurance claim as a function of the second set of insurance claim assessment data entered by the second user during a second insurance claim consultation session.
- the present invention provides various embodiments of a method and system for hosting an insurance claim processing system according to a pricing model.
- the method may include hosting an insurance claim processing server which is configured to estimate a value of an insurance claim as a function of insurance claim assessment data entered by a user during an insurance claim consultation session.
- the insurance claim may include a bodily injury claim, and the estimate of the value of the insurance claim may include an estimate of bodily injury general damages.
- the method may further include charging the user for access to the insurance claim processing server through client software according to a pricing model.
- the client software may be operable to receive the insurance claim assessment data entered by the user and send the insurance claim assessment data across a network to the insurance claim processing server.
- the insurance claim processing server may be operable to send the estimate of the value of the insurance claim to the client software across the network.
- the network may include the Internet.
- the insurance claim processing server may include a rules engine and a web server, and the client software may include a web browser.
- the web server may be operable to generate web pages and receive responses and requests from the web browser to enable communication between the rules engine and the web browser.
- the method may further include charging additional users for access to the insurance claim processing server through client software according to a same or different pricing model.
- the pricing model may include a fee for each of a plurality of insurance claim consultation sessions conducted by the user.
- the pricing model may include a fee for each fixed period of access time of access by the user to the insurance claim processing server through the client software.
- the fixed period of access time may include an hourly multiple, a weekly multiple, a monthly multiple, a yearly multiple, or a multiple of minutes.
- the pricing model may include a fee which varies directly with an amount of time spent accessing the insurance claim consultation session through the client software.
- the user may include an insurance organization having a particular size, and the pricing model varies according to the size of the user.
- the size of the user may include a function of a quantity of employees of the user, a function of a revenue of the user over a period of time, and/or a function of a quantity of consultation sessions conducted by the user over a period of time.
- the pricing model may include a pricing discount given to the user after a particular quantity of insurance claim consultation sessions conducted by the user in a particular period of time.
- the insurance claim consultation session may include one or more insurance claim consultation transactions, and the pricing model may include a fee for each of a plurality of insurance claim consultation transactions conducted by the user during one or more insurance claim consultation sessions.
- Figure la is a block diagram illustrating the architecture of one embodiment of an insurance claims processing system
- Figure lb illustrates one embodiment of a networked insurance claim processing system
- Figure lc is a block diagram illustrating the architecture of one embodiment of an insurance claims processing system
- Figure 2 illustrates a structure for an insurance claims processing help database that may be used for context sensitive help and for searching for terms according to one embodiment of an insurance claim processing system;
- Figure 3 illustrates a table including document header information according to one embodiment of an insurance claim processing system
- Figure 4 illustrates a table including document text information according to one embodiment of an insurance claim processing system
- Figure 5 illustrates an index table including terms and codes and cross-references to other tables according to one embodiment of an insurance claim processing system
- Figure 6a is a flow diagram illustrating a method for generating the various tables in an insurance claims processing help database according to one embodiment of an insurance claim processing system
- Figures 6b through 6h are flow diagrams illustrating a mechanism for generating relevance values for occurrences in an insurance claims processing help database according to one embodiment of an insurance claims processing system
- Figures 7a-7c are flow diagrams illustrating a mechanism for providing context-sensitive help according to one embodiment of an insurance claim processing system
- Figure 8 illustrates a display screen showing multiple panes, wherein two of the panes comprise context sensitive help information, according to one embodiment of an insurance claim processing system
- Figure 9 is a flow diagram illustrating a mechanism for searching for insurance claims processing terms according to one embodiment of an insurance claim processing system
- Figure 10 illustrates a display screen showing multiple panes, wherein two of the panes comprise search results information, according to one embodiment of an insurance claim processing system; and Figure 11 shows the display screen of Figure 10, with one of the search results panes hidden to provide more display area for claims processing information, according to one embodiment of an insurance claim processing system;
- Figure Id is a network diagram of an illustrative distributed computing environment which is suitable for implementing various embodiments
- Figure 2aA is an illustration of an insurance claims processing server computer architecture according to one embodiment
- Figure 2bA is an illustration of an insurance claims processing client computer architecture according to one embodiment
- Figure 3aA is an illustration of an insurance claims processing server software architecture for a single client according to one embodiment
- Figure 3bA is an illustration of an insurance claims processing server software architecture for multiple clients according to one embodiment
- Figure 4A is an illustration of adapter software between a rules engine and a web server according to one embodiment
- Figure 5A illustrates the transmission of data between a web server and a web browser according to one embodiment
- Figure 6A illustrates an example of a browser-based user interface for the insurance claims processing system according to one embodiment
- Figure 7A is a flowchart illustrating a method of developing a web-based insurance claims processing system according to one embodiment
- Figure 8A is a flowchart illustrating a method of hosting a web-based insurance claims processing server with various pricing models according to one embodiment
- Figure 9A is a flowchart illustrating a method of using a reset button provided by a web-based interface to a web-based insurance claims processing server according to one embodiment
- Figure 2B illustrates a flow chart to generate a table of contents for processing an insurance claim according to one embodiment
- Figure 3B illustrates detail of step 150B in Figure 2B
- Figure 4B is a flowchart illustrating the use of a table of contents for processing an insurance claim according to one embodiment
- Figure 5B illustrates a screen shot of a table of contents display screen according to one embodiment
- Figure 6B illustrates exemplary properties and methods associated with a display screen object according to one embodiment
- Figure 2C is a flow chart illustrating the process of identifying critical factors affecting the fair estimate value, included in an insurance claim consultation report, according to one embodiment
- Figure 3C illustrates a table for storing injury codes, treatment codes and contributing factor values according to one embodiment
- Figure 2D illustrates a flow chart to transform formula data to formulas for assessing bodily injury damages claims according to one embodiment
- Figure 3D illustrates data elements of a formula table according to one embodiment
- Figure 2E illustrates a flow chart to transform rules data to rules for assessing bodily injury damages claims according to one embodiment
- Figure 3aE illustrates data elements of a rules data table according to one embodiment
- Figure 3bE illustrates data elements of a template table according to one embodiment
- Figure 3cE illustrates data elements of a line text table according to one embodiment
- Figure 4E illustrates a block diagram of the transformation of rules data to rules for assessing bodily injury damages according to one embodiment
- Figure 2F is a flowchart illustrating a method of generating messages associated with processing an insurance claim according to one embodiment
- Figure 3F is a flowchart illustrating a method of using a messages table associated with processing an insurance claim according to one embodiment
- Figure 4F is an exemplary diagram of a messages table in a database according to one embodiment.
- Figure la A block diagram illustrating the architecture of one embodiment of an insurance claims processing system
- an embodiment of an insurance claims processing system 10 may include a computer system 20.
- the term "computer system” as used herein generally includes the hardware and software components that in combination allow the execution of computer programs.
- the computer programs may be implemented in software, hardware, or a combination of software and hardware.
- a computer system's hardware generally includes a processor, memory media, and Input/Output (I O) devices.
- processor generally describes the logic circuitry that responds to and processes the basic instructions that operate a computer system.
- memory is used synonymously with “memory medium” herein.
- memory medium is intended to include an installation medium, e.g., a CD-ROM, or floppy disks, a volatile computer system memory such as DRAM, SRAM, EDO RAM, Rambus RAM, etc., or a non-volatile memory such as optical storage or a magnetic medium, e.g., a hard drive.
- the memory medium may comprise other types of memory as well, or combinations thereof.
- the memory medium may be located in a first computer in which the programs are executed, or may be located in a second different computer which connects to the first computer over a network. In the latter instance, the second computer provides the program instructions to the first computer for execution.
- the computer system may take various forms, including a personal computer system, mainframe computer system, workstation, network appliance, Internet appliance, personal digital assistant (PDA), television system or other device.
- the term "computer system” can be broadly defined to encompass any device having a processor which executes instructions from a memory medium.
- the memory medium preferably stores a software program or programs for processing insurance claims as described herein.
- the software program(s) may be implemented in any of various ways, including procedure- based techniques, component-based techniques, and/or object-oriented techniques, among others.
- the software programs may be implemented using a rule-based development tool such as PLATINUM AionTM available from Computer Associates International, Inc.
- PLATINUM AionTM may combine business rule and object-oriented technologies to create and maintain complex, knowledge-intensive applications.
- Software developed with PLATINUM AionTM may employ an AionTM programming language for automation of processes which may use hundreds or thousands of business rules from a knowledge base.
- An AionTM inference engine may automatically determine which rules to execute, when, and in what order.
- the software program may be implemented using other technologies, languages, or methodologies, as desired.
- a CPU such as the host CPU, executing code and data from the memory medium includes a means for creating and executing the software program or programs according to the methods, flowcharts, and/or block diagrams described below.
- a computer system's software generally includes at least one operating system, a specialized software program that manages and provides services to other software programs on the computer system.
- Software may also include one or more programs to perform various tasks on the computer system and various forms of data to be used by the operating system or other programs on the computer system.
- the data may include but are not limited to databases, text files, and graphics files.
- a computer system's software generally is stored in non-volatile memory or on an installation medium.
- a program may be copied into a volatile memory when running on the computer system. Data may be read into volatile memory as the data is required by a program.
- a server may be defined as a computer program that, when executed, provides services to other computer programs executing in the same or other computer systems.
- the computer system on which a server program is executing may also be referred to as a server, though it may contain a number of server and client programs.
- a server is a program that awaits and fulfills requests from client programs in the same or other computer systems.
- the insurance claims processing system 10 may further include a display screen 50 connected to the computer system 20 and an insurance database 40 residing on an internal or external storage.
- the database may also be referred to as a repository.
- a “database” may include a collection of information from which a computer program may select a desired piece of data.
- an "insurance database” is used as a synonym for a “database” when included in or coupled to an insurance claims processing system 10.
- System 20 includes memory 30 configured to store computer programs for execution on system 20, and a central processing unit (not shown) configured to execute instructions of computer programs residing on system 20.
- Claims processing program 60 also referred to as application program software 60, may be stored in memory 30.
- an "insurance claims processing program” 60 may include a software program which is configured to conduct transactions regarding insurance claims, such as by estimating the value of the insurance claims, for example.
- the insurance claims processing system 10 may be used by an Insurance Company for various embodiments of a system and method for processing insurance claims using a Table of Contents (TOC).
- an Insurance Company includes a business organization that provides insurance products and/or services to customers. More particularly, the insurance products may pertain to providing insurance coverage for accidents and the trauma-induced bodily injuries that may result due to the accident. Examples of trauma-induced bodily injuries may include, but are not limited to: loss of limb(s); bone fractures; head, neck and/or spinal injury, etc.
- a customer may file an insurance claim with his/her insurance organization to cover medical and other accident-related expenses.
- An IC may utilize a computer-based insurance claim processing system to process insurance claims.
- the processing may include estimating a value associated with the filed insurance claim.
- an IC business transaction may be defined as a service of an IC. Examples of business transactions include, but are not limited to: insurance transactions such as filing of claims, payment of claims, application for insurance coverage, and customized benefits, etc. Business transactions may also include services related to customers, insurance providers, employers, insurance agents, investigators, etc.
- an IC insurance claim processing includes a series of instructions executed by a computer system for processing an IC's business transactions.
- a claim processing system may include one or more processing tasks.
- a processing task may include a sequence of one or more processing steps or an ordered list or a structured list of one or more processing steps, associated with the business transaction to be processed by the claim processing system.
- the sequence of steps may be fixed.
- the sequence of steps may be established dynamically, in real-time.
- the sequence of one or more steps may include an initial step, a final step, one or more intermediary steps, etc.
- an IC user may select steps to process an insurance claim in a sequential manner.
- the IC user may select steps to process an insurance claim in a random or arbitrary manner.
- processing steps may include, but are not limited to: receiving an input from a user of the IC insurance claim processing system, reading a value from a database, updating a field in a database, displaying the results of a business transaction on a computer screen, etc.
- the insurance claim processing system utilizes object-oriented technology to process insurance claims.
- processing of insurance claims may utilize traditional programming languages and databases to achieve the same result.
- Insurance objects may be defined to represent or model real- world business features of insurance products and services. Examples of insurance objects may include, but are not limited to, objects representing the following: an insurance claim; an accident report; a settlement; an estimated claim; IC service facilities, customers, and employees; business process such as a new insurance application and calculation of a premium; interfaces to external insurance organizations; work tasks such as calculations, decisions, and assignments; temporal objects such as calendars, schedulers, and timers; and elemental data necessary to accomplish work tasks such as medical costs, risk factors, etc.
- An insurance object may be represented on the computer screen by a graphical icon or by a display listing the properties of the insurance object in graphic and alphanumeric format.
- An insurance claim object may be configured to gather and evaluate data for processing a filed insurance claim and to automatically make decisions about the insurance claim.
- the one or more processing steps associated with the processing of an insurance claim may also be configured as one or more processing step objects.
- a display screen may be associated with a processing step.
- the display screen may also be represented as an object.
- Each display screen object may include a property to point to a previous display and another property to point to a next display screen.
- Each property, e.g. the next display pointer on a display screen object may be changed dynamically by using methods associated with the display screen object.
- One display screen object may serve as the starting point for processing insurance claims.
- the starting point for processing insurance claims may include acquiring an insurance claim identification number from an IC system user.
- a business rule and/or an IC system user input may determine that the insurance claim processing needs the execution of additional steps or tasks to continue the processing of the claim.
- the IC system user may provide inputs to the insurance claims processing program 60 at any display screen associated with a step included in the Table of Contents (see Figure 2 for a discussion of the generation of the Table of Contents according to one embodiment).
- the insurance claim processing software may dynamically modify the number of steps and/or the sequence of their execution to complete the claim processing transaction. An IC system user working at a client system may then iterate through the claim processing steps and arrive at an estimated value for the insurance claim.
- the program 60 may provide a graphical user interface to display claims processing related information on display screen 50. It may collect user inputs, entered by using user input devices 52, and associated with insurance claims. It may process the user inputs, access an insurance database 40, use the contents of the insurance database 40 to estimate the insurance claim, and store it in memory 30 and/or insurance database 40.
- the program 60 may display a value of the estimated insurance claim on display screen 50. A user may view the display of the estimated insurance claim on display screen 50, and may interactively make modifications, additions, and deletions to the estimated insurance claim.
- System 20 may also include one or more user input devices 52, such as a keyboard, for entering data and commands into the insurance claim program 60. It may also include one or more cursor control devices 54 such as a mouse for using a cursor to modify an insurance claim viewed on display screen 50. In response to the updating of the estimated insurance claim, the insurance claim program 60 may store the updated insurance claim in the insurance database 40.
- user input devices 52 such as a keyboard
- cursor control devices 54 such as a mouse for using a cursor to modify an insurance claim viewed on display screen 50.
- the insurance claim program 60 may store the updated insurance claim in the insurance database 40.
- Figure lb One embodiment of a networked insurance claim processing system
- Figure lb illustrates one embodiment of a networked system, configured for processing insurance claims.
- the system is shown as a client server system with the server systems and client systems connected by a network 62.
- Network 62 may be a local area network or wide area network, and may include communications links including, but not limited to: Ethernet, token ring, internet, satellite, and modem.
- Insurance claims processing system 10 as illustrated in Figure la may be connected to network 62.
- the insurance claim processing system software and insurance database 40 may be distributed among the one or more servers 70 to provide a distributed processing system for insurance claim transactions.
- an insurance claim processing transaction being processed by the insurance claim processing system may be routed to any server based upon the workload distribution among servers 70 at the time of the transaction.
- Insurance claim processing system servers 70 may be located on a local area network or may be geographically dispersed in a wide area network.
- One or more client systems 80 may also be connected to network 62.
- Client systems 80 may reside at one or more claim processing units within the insurance company. In a wide area network, client systems 80 may be geographically dispersed. Client systems 80 may be used to access insurance claim processing system servers 70 and insurance database 40. An insurance claim-processing employee may use a client system 80 to access the insurance claim processing system and execute insurance transactions. An employee may also use a client system 80 to enter insurance claim inputs into the insurance claim processing system.
- One or more printers 90 may also be connected to network 62 for printing documents associated with insurance claim transactions.
- Various embodiments further include receiving or storing instructions and/or data implemented in accordance with the description herein upon a carrier medium.
- Suitable carrier media include memory media or storage media such as magnetic or optical media, e.g., disk or CD-ROM, as well as transmission media or signals such as electrical, electromagnetic, or digital signals, conveyed via a communication medium such as networks and/or a wireless link.
- an embodiment of an insurance claims processing system 10 may include a computer system 20.
- the term "computer system” as used herein generally includes the hardware and software components that in combination allow the execution of computer programs.
- the computer programs may be implemented in software, hardware, or a combination of software and hardware.
- a computer system's hardware generally includes a processor, memory media, and Input/Output (I/O) devices.
- processor generally describes the logic circuitry that responds to and processes the basic instructions that operate a computer system.
- memory is used synonymously with “memory medium” herein.
- memory medium is intended to include an installation medium, e.g., a CD-ROM, or floppy disks, a volatile computer system memory such as DRAM, SRAM, EDO RAM, Rambus RAM, etc., or a non- volatile memory such as optical storage or a magnetic medium, e.g., a hard drive.
- the memory medium may comprise other types of memory as well, or combinations thereof.
- the memory medium may be located in a first computer in which the programs are executed, or may be located in a second different computer that connects to the first computer over a network. In the latter instance, the second computer provides the program instructions to the first computer for execution.
- the computer system may take various forms, including a personal computer system, mainframe computer system, workstation, network appliance, Internet appliance, personal digital assistant (PDA), television system or other device.
- PDA personal digital assistant
- the term "computer system” can be broadly defined to encompass any device having a processor that executes instructions from a memory medium.
- the memory medium preferably stores a software program or programs for processing insurance claims as described herein.
- the software program(s) may be implemented in any of various ways, including procedure- based techniques, component-based techniques, and/or object-oriented techniques, among others.
- the software programs may be implemented using a rule-based development tool such as PLATINUM AionTM available from Computer Associates International, Inc.
- PLATINUM AionTM may combine business rule and object-oriented technologies to create and maintain complex, knowledge-intensive applications.
- Software developed with PLATINUM AionTM may employ an AionTM programming language for automation of processes which may use hundreds or thousands of business rules from a knowledge base.
- An AionTM inference engine may automatically determine which rules to execute, when, and in what order.
- the software program may be implemented using other technologies, languages, or methodologies, as desired.
- a CPU such as the host CPU, executing code and data from the memory medium includes a means for creating and executing the software program or programs according to the methods, flowcharts, and/or block diagrams described below.
- a computer system's software generally includes at least one operating system, a specialized software program that manages and provides services to other software programs on the computer system.
- Software may also include one or more programs to perform various tasks on the computer system and various forms of data to be used by the operating system or other programs on the computer system.
- the data may include but are not limited to databases, text files, and graphics files.
- a computer system's software generally is stored in non-volatile memory or on an installation medium.
- a program may be copied into a volatile memory when running on the computer system. Data may be read into volatile memory as required by a program.
- a server may be defined as a computer program that, when executed, provides services to other computer programs executing in the same or other computer systems.
- the computer system on which a server program is executing may also be referred to as a server, though it may contain a number of server and client programs.
- a server is a program that awaits and fulfills requests from client programs in the same or other computer systems.
- the insurance claims processing system 10 may further include a display screen 50 connected to the computer system 20 and an insurance database 40 residing on an internal or external storage.
- the database may also be referred to as a repository.
- a “database” may include a collection of information from which a computer program may select a desired piece of data.
- an "insurance database” is used as a synonym for a “database” when included in or coupled to an insurance claims processing system 10.
- System 20 includes memory 30 configured to store computer programs for execution on system 20, and a central processing unit (not shown) configured to execute instructions of computer programs residing on system 20.
- Claims processing program 60 also referred to as application program software 60, may be stored in memory 30.
- an "insurance claims processing program” 60 may include a software program which is configured to conduct transactions regarding insurance claims, such as by estimating the value of the insurance claims, for example.
- the insurance claims processing system 10 may be used by an Insurance Company for various embodiments of a system and method for processing insurance claims.
- an Insurance Company includes a business organization that provides insurance products and/or services to customers. More particularly, the insurance products may pertain to providing insurance coverage for accidents and the trauma- induced bodily injuries that may result due to the accident. Examples of trauma-induced bodily injuries may include, but are not limited to: loss of limb(s); bone fractures; head, neck and or spinal injury, etc.
- a customer may file an insurance claim
- An IC may utilize a computer-based insurance claim processing system to process insurance claims.
- the processing may include estimating a value associated with the filed insurance claim.
- an IC business transaction may be defined as a service of an IC.
- Examples of business transactions include, but are not limited to: insurance transactions such as filing of claims, payment of claims, application for insurance coverage, and customized benefits, etc.
- Business transactions may also include services related to customers, insurance providers, employers, insurance agents, investigators, etc.
- an IC insurance claim processing includes a series of instructions executed by a computer system for processing an IC's business transactions.
- a claim processing system may include one or more processing tasks.
- a processing task may include a sequence of one or more processing steps or an ordered list or a structured list of one or more processing steps, associated with the business transaction to be processed by the claim processing system.
- the sequence of steps may be fixed.
- the sequence of steps may be established dynamically, in real-time.
- the sequence of one or more steps may include an initial step, a final step, one or more intermediary steps, etc.
- an IC user may select steps to process an insurance claim in a sequential manner.
- the IC user may select steps to process an insurance claim in a random or arbitrary manner.
- processing steps may include, but are not limited to: receiving an input from a user of the IC insurance claim processing system, reading a value from a database, updating a field in a database, displaying the results of a business transaction on a computer screen, etc.
- the insurance claim processing system utilizes object-oriented technology to process insurance claims.
- processing of insurance claims may utilize traditional programming languages and databases to achieve the same result.
- Insurance objects may be defined to represent or model real- world business features of insurance products and services. Examples of insurance objects may include, but are not limited to, objects representing the following: an insurance claim; an accident report; a settlement; an estimated claim; IC service facilities, customers, and employees; business process such as a new insurance application and calculation of a premium; interfaces to external insurance organizations; work tasks such as calculations, decisions, and assignments; temporal objects such as calendars, schedulers, and timers; and elemental data necessary to accomplish work tasks such as medical costs, risk factors, etc.
- An insurance object may be represented on the computer screen by a graphical icon or by a display listing the properties of the insurance object in graphic and/or alphanumeric format.
- An insurance claim object may be configured to gather and evaluate data for processing a filed insurance claim and to automatically make decisions about the insurance claim.
- the one or more processing steps associated with the processing of an insurance claim may also be configured as one or more processing step objects.
- a display screen which also may be referred to as a page, may be associated with a processing step.
- the display screen may also be represented as an object.
- Each display screen object may include a property to point to a previous display and another property to point to a next display screen.
- Each property e.g.
- the next display pointer on a display screen object may be changed dynamically by using methods associated with the display screen object.
- One display screen object may serve as the starting point for processing insurance claims.
- the starting point for processing insurance claims may include acquiring an insurance claim identification number from an IC system user.
- a business rule and or an IC system user input may determine that the insurance claim processing needs the execution of additional steps or tasks to continue the processing of the claim.
- the IC system user may provide inputs to the insurance claims processing program 60 at any display screen associated with a step included in the Table of Contents.
- the insurance claim processing software may dynamically modify the number of steps and/or the sequence of their execution to complete the claim processing transaction. An IC system user working at a client system may then iterate through the claim processing steps and arrive at an estimated value for the insurance claim.
- the program 60 may provide a graphical user interface to display claims processing related information on display screen 50. It may collect user inputs, entered by using user input devices 52, and associated with insurance claims. It may process the user inputs, access an insurance database 40, use the contents of the insurance database 40 to estimate the insurance claim, and store it in memory 30 and/or insurance database 40.
- the program 60 may display a value of the estimated insurance claim on display screen 50. A user may view the display of the estimated insurance claim on display screen 50, and may interactively make modifications, additions, and deletions to the estimated insurance claim.
- System 20 may also include one or more user input devices 52, such as a keyboard, for entering data and commands into the insurance claim program 60. It may also include one or more cursor control devices 54 such as a mouse for using a cursor to modify an insurance claim viewed on display screen 50. In response to the updating of the estimated insurance claim, the insurance claim program 60 may store the updated insurance claim in the insurance database 40.
- user input devices 52 such as a keyboard
- cursor control devices 54 such as a mouse for using a cursor to modify an insurance claim viewed on display screen 50.
- the insurance claim program 60 may store the updated insurance claim in the insurance database 40.
- the insurance claims processing system may provide context-sensitive help for the processing steps.
- the context-sensitive help for the step may be automatically invoked and displayed on display screen 50 when entering the step.
- the user may interactively invoke context-sensitive help for the step by selecting one or more interface items on the display screen 50 with a cursor control device 54 such as a mouse.
- the user may interactively invoke context-sensitive help for the step by using an input device 52. For example, the user may select one or more keys or a combination of keys on a keyboard to activate context-sensitive help.
- the context-sensitive help for each processing step may be unique, although content may appear in the context-sensitive help for two or more processing steps.
- Help database 400 may include one or more one or more documents including information that may be useful to a user in performing the various processing steps associated with insurance claims processing.
- Help database 400 may also include one or more tables that provide access to the information in the documents. Each table may include a plurality of records or entries that may be used to locate help information about processing steps and/or the elements in processing steps in the one or more documents in the help database 400.
- a search interface may be provided in the insurance claims processing system.
- a user may enter in the search interface one or more terms to be searched for in help database 400 for the insurance claims processing system.
- the user may then initiate the search for the one or more terms.
- the insurance claims processing system may then search the help database 400 for entries including at least one of the one or more terms.
- the insurance claims processing system may locate one or more entries in the help database 400 that include at least one of the one or more terms.
- the insurance claims processing system may then display information on display screen 50 from the located help database 400 entries.
- Figure 2 illustrates one embodiment of an insurance claims processing help database 400 that may be used for context sensitive help and for searching for terms in an insurance claim processing system.
- Help database may include one or more index tables 402, one or more header tables 404, one or more text tables 406, and one or more documents 408.
- One embodiment may include one index table 402, one header table 404, and one text table 406.
- the header table 404 and text table 406 may be combined into one master table comprising entries for header portions and text portions of the one or more documents 408.
- Index tables 402, header tables 404, and text tables 406 may each include one or more records or entries.
- the entries in index tables 402 may each include a field comprising one or more terms or codes that may be used as keys for locating entries in header tables 404 and/or text tables 406.
- the entries in index tables 402 may each also include information for locating an entry in one of the one or more header tables 404 or text tables 406.
- an identification number may be used to identify each entry in the one or more header tables 404 and text tables 406. The identification number may be referred to herein as an object ID.
- each entry in the index tables 402 may include an object ID that identifies, and that may be used to locate, one entry in one of the header tables 404 or text tables 406.
- index tables 402 may include two or more entries that include the same object ID.
- two or more index table 402 entries may indicate, or point to, the same entry in a header table 404 or text table 406.
- Each entry in index tables 402 may be referred to as an occurrence of the term or code included in the index table 402 entry in the help database 400.
- each entry in the header tables 404 and text tables 406 may include a unique object ID that may be used to locate the entry.
- each entry in the header tables 404 may include a field containing a header or a portion of a header from one of the one or more documents 408.
- each entry in the header tables 404 may include information that may be used to locate a header or a portion of a header in one of the one or more documents 408.
- each entry in the text tables 404 may include a field containing a text section or a portion of a text section from one of the one or more documents 408.
- each entry in the text tables 406 may include information that may be used to locate a text section or a portion of a text section in one of the one or more documents 408.
- Index table may include index entries 410 and 412.
- Index entry 410 may include a term or code included in a header of one of the documents 408.
- Index entry 410 may include an object ID that may be used to locate header entry 414 in one of the header tables 404.
- Header entry 414 may include a portion or all of header 418 from one of the one or more documents 408.
- header entry 414 may include information that may be used to locate header 418 in one of the one or more documents 408. If index entry 410 includes a term, then the term may appear one or more times in header 418 and/or in the portion of header 418 included in header entry 414.
- index entry 410 includes a code
- the code may indicate the index table entry 410 refers to a particular header or portion of a header in its entirity (i.e. this is not an occurrence of a term).
- codes may be used to identify headers or sections of text in documents 408.
- codes may be included as "hidden" text in one or more sections of documents 408, and may be used in constructing header tables 404 and text tables 406.
- Index entry 412 may include a term or code included in a text section of one of the documents 408.
- Index entry 412 may include an object ID that may be used to locate text entry 416 in one of the text tables 406.
- Text entry 416 may include a portion or all of text section 420 from one of the one or more documents 408.
- text entry 416 may include information that may be used to locate text 420 in one of the one or more documents 408. If index entry 412 includes a term, then the term may appear one or more times in text section 420 and/or in the portion of text section 420 included in text entry 416. If index entry 412 includes a code, then the code may indicate the index table entry 412 refers to a particular text section or portion of a text section (i.e. this is not an occurrence of a term).
- index tables 402 Embodiments of index tables 402, header tables 404 and text tables 406 are further described in Figures 3, 4, and 5, respectively.
- Figure 3 A table including document header information
- Figure 3 illustrates one embodiment of a table including header information from one or more documents
- the header table 404 may include a plurality of records, also referred to as entries, with one entry for each header element from the one or more documents 408 to be included in a help database 400 for the insurance claims processing system.
- Each entry may comprise a plurality of fields, which also may be referred to as elements of the entry.
- An entry may include an object identifier (object ID) 100 for the entry.
- object ID object identifier
- the object ID 100 for the entry may be unique in the help database 400.
- the object ID 100 may include information that may be used to identify the document that includes the header, and the location in the document of the header.
- the object ID 100 of the first entry in the header table 404 of Figure 3 may indicate that the entry is for the header of the first chapter of a first document included in the help database 400
- the object ID 100 of the second entry may indicate that the entry is for the header of the first section of the first chapter of the first document, and so on.
- An entry may also include the object identifier of a parent entry (parent ID 102) for the entry.
- parent ID 102 the parent ID 102 of the entries for the headers of several sections in the first chapter of a document may be the object ID 100 of the entry for the header of the chapter.
- An entry in the header table 404 may also include information on the location in the document of the header.
- byte count 104 may represent the byte (character) location in the document of the start of the header.
- the header of the first entry in the header table 404 illustrated in Figure 3 may start at the first byte of the document, the header of the second entry may start at the 26* byte of the document, etc.
- an entry in the header table 404 may also include the alphanumeric text of the header from the document in name field 106.
- the header text in name 106 may be read from the header table and displayed on the display screen for the user to view.
- the entry may not store the actual text for the header, but may instead include information for locating the text for the header in the document. In this embodiment, when the entry is located, the actual text of the header may be read from the document itself and displayed for the user.
- Figure 4 A table including document text information
- Figure 4 illustrates one embodiment of a table including text information from one or more documents 408 related to insurance claims processing.
- the text table 406 may include a plurality of entries, with one entry for each text section from the one or more documents 408 to be included in the help database 400 for the insurance claims processing system.
- Each entry may comprise a plurality of fields, which also may be referred to as elements of the entry.
- the fields may be substantially similar to the fields in embodiments of the header table 404 as illustrated in Figure 3.
- An entry may include an object identifier 110 (object ID), for the entry.
- object ID 110 for the entry may be unique in the help database 400.
- the object ID 110 may include information that may be used to identify the document including the text section and the location in the document of the text section.
- Object ID 110 may also include information to distinguish a text table 406 entry from a header table 404 entry. For example, a non-zero last digit in the object ID 110 may indicate that the entry is a text table 406 entry and not a header table 404 entry.
- the entry may also include the object identifier of a parent entry (parent ID 112) for the entry.
- the parent ID 112 may point to an entry in the text table 406 as the parent of the entry.
- the entry may also include a text field 116 that may include some or all of the text from a section of one of the one or more documents 408 in the help database 400.
- a text field 116 may include some or all of the text from a section of one of the one or more documents 408 in the help database 400.
- the text in text field 116 may be read from the text table and displayed on the display screen for the user to view.
- the entry may not store the actual text, but may instead include information for locating the text in the document. In this case, when the entry is located, the actual text may be read from the document itself and displayed for the user.
- the order of the columns and rows in the text table illustrated in Figure 4 is exemplary and is not intended to be limiting.
- FIG. 5 An index table Figure 5 illustrates one embodiment of an index table 402 for locating terms and/or codes for context- sensitive help and for interactively searching for terms in the help database 400.
- Each entry in the index table 402 may represent an occurrence of a term or code in the one or more documents 408 included in the help database 400 for the insurance claims processing system.
- documents that may be included in the help database 400 for the insurance claims processing system include, but are not limited to: medical journals, textbooks and/or manuals, insurance claims processing manuals or guidebooks, medical glossaries and/or dictionaries, and documents including context sensitive help entries for the insurance claims processing steps, and elements of the steps, in the insurance claims processing system.
- An entry in the index table 402 may include an object ID 140.
- the object ID 140 may indicate a unique entry in a help information table in the help database.
- the help database may include one or more header tables 404 as illustrated in Figure 3 and one or more text tables 406 as illustrated in Figure 4.
- An entry in the index table may also include a term field 142.
- term field 142 may include one or more terms located in the one or more documents 408 in the help database 400.
- term field 142 may include a code representing a step or page in the insurance claims processing system or an element in a step in the insurance claims processing system. The codes may be used in invoking context-sensitive help in the insurance claims processing system.
- One embodiment may include one or more entries with one or more terms in term field 142 and one or more entries with codes in term field 142.
- An entry in the index table 402 may also include a Soundex field 144.
- Soundex is a commonly used algorithm for encoding words so that similar sounding words encode the same.
- the first letter of a word to be converted to a Soundex equivalent may be copied unchanged, and then subsequent letters may be encoded as follows:
- column 146 may indicate the position of the term or code in the text section or header in which this occurrence of the term or code appears.
- Column 148 may indicate the total count of words in the text section or header. For example, in the first entry of the index table 402 as illustrated in Figure 5, the position column 146 indicates that the term "System” appears as the fifth word of the 54 words (from the total words column 148) in the text section indicated by the object ID column 140. Examining the second entry, the term "System” appears again as the ninth word of the same text section.
- the word count column 150 may be used with entries for headers in calculating the relevance value 152. Different information and methods may be used for calculating the relevance of occurrences of terms and codes appearing in headers than the information and methods used to calculate the relevance for terms and codes appearing in text sections. In calculating the relevance for headers, the percent of the total word count indicated in column 150 may be used as part of the calculation.
- the word count 150 indicates how many words make up the one or more words (or words represented by a code) as represented in column 142. For example, in the header entry in the seventh row of the index table as illustrated in Figure 5, the term "Anatomy" is in the third position (as indicated by column 146) of three words (as indicated by column 148) and includes one word.
- the last column of the index table 402 illustrated in Figure 5 may hold a calculated relevance 152 for the occurrence.
- the relevance may be calculated in advance for all occurrences.
- the relevance for occurrences may not be calculated in advance and stored in the index table 402, but instead may be calculated dynamically as needed.
- columns 146, 148, and 150 may not be stored in the index table 402. Instead, the information may be used to calculate the relevance and then discarded.
- One embodiment of the index table 402 may include only an object ID 140, a term 142, and a relevance value 152.
- Another embodiment of an index table 402 may only include an object ID 140 and a term 142, and the relevance may be calculated dynamically.
- occurrences in headers may be considered of higher relevance than occurrences in text sections. Therefore, different methods may be applied to calculate the relevance of occurrences in headers than are applied to calculate the relevance of occurrences in text sections.
- relevance values may be scaled to be between 0.0 and 1.0, with 1.0 being the highest relevance.
- the relevance may be calculated so that a relevance value of 0.0 does not occur. Note that any scale may be used for the relevance calculation, as it may be the ordering of the relevance values that is useful, and not necessarily the scale on which the relevance values are calculated.
- a maximum relevance value may be provided for occurrences in text sections. This maximum value may be applied as a weight or scaling factor during the relevance calculation.
- the maximum relevance value for occurrences in text sections may also serve as the minimum value for occurrences in headers.
- header occurrences may always have at least as high a relevance value as the highest relevance text occurrences.
- header occurrences may always have a higher relevance value than the highest relevance text occurrences.
- a user of the insurance claims processing system may begin processing of an insurance claim.
- the system may enter the first step in the processing of the claim.
- the first step may be displayed in a "page" on the display screen for the user.
- Information about the first step and the display page for the first step may be stored in the computer executing the insurance claims processing system.
- a code for the step which may also be viewed as a code for the page, may be stored.
- the code may be read from the information, and the context-sensitive help system may search the index table 402 for one or more enfries with a code in term field 142 matching the code for the step.
- the context-sensitive help system may locate one or more entries in the header tables 404 and/or text tables 406 in the help database 400 corresponding to the object IDs 140 in the entries in the index table 402.
- the header and text from the located one or more entries in the header tables 404 and/or text tables 406 may then be displayed as help information items on the display screen for the user.
- the help information items may be displayed in an order of relevance using the relevance values 152 for the located entries in the index table 402.
- Elements within a step may also be given a code, and the code may be included in one or more entries in the index table 402.
- one or more codes for one or elements of the step may also be read from stored information about the step. Occurrences of help information for the one or more codes may be searched for, ranked by relevance, and displayed similarly to, and along with, the code for the step as described above.
- the order of the columns and rows in the index table 402 illustrated in Figure 5 is exemplary and is not intended to be limiting.
- Figure 6a is a flow diagram illustrating one embodiment of a mechanism for generating an insurance claims processing help database 400.
- one or more documents may be processed into header tables 404 and text tables 406.
- one entry is added to a header table 404 for each header in the one or more documents 408 in the help database 400.
- one entry may be added to a text table 406 for each text section in the one or more documents 408 in the help database 400.
- An object ID may be assigned to each entry added to a header table 404 or text table 406.
- a parent ID of each entry may also be identified. The number of bytes in the section of text or header for the entry may also be determined.
- the entry for each occurrence may include the object ID, parent ID, byte count and text section for text table 406 entries or header text for header table 404 entries.
- one or more index tables 402 may be generated.
- a plurality of terms may be searched for in the header text of the enfries in the one or more header tables 404 and in the text section of the entries in the one or more text tables 406.
- Each located occurrence of each term may be recorded as an entry in an index table 402.
- one or more codes may be associated with headers and/or text sections in the one or more documents, and the one or more codes may be searched for in the header tables 404 and text tables 406.
- Each located occurrence of each code may be recorded as an entry in an index table 402.
- a code may be used to identify a particular section of text or header in the one or more documents 408.
- a code may be used to identify a section of text that may be displayed as the context sensitive help for a step in the insurance claims processing step.
- an entry may be added to the index table for each occurrence of a term or code located in the name field 106 of an entry in a header table 404 or in the text field 116 of an entry in a text table 406.
- the object ID of the header table 404 entry or text table 406 entry where each occurrence was located may be inserted in the object ID field 140 of the index table 402 entry for the occurrence.
- one or more other fields may be added to the enfries in the index table 402.
- a Soundex equivalent 144 may be added to entries that include a term in the term field 142. In one embodiment, a Soundex equivalent 144 may not be added for entries with a code in the term field 142.
- the position of the term or code in the text section or header in which this occurrence of the term or code appears may be entered in a position field 146.
- the total count of words in the text section or header may be entered in a total words field 148.
- a word count 150 may be entered that indicates the number of words in the term 142 for this occurrence.
- a word count of zero may be entered.
- the relevance value 152 for each occurrence may be calculated and entered in index table
- the relevance value 152 for each occurrence may be calculated up front, when the help database tables are generated. In another embodiment, the relevance value 152 for an occurrence may be calculated dynamically when the occurrence is located for display in the insurance claims processing system. In this embodiment, the index table 402 may not include a relevance value 152 for each occurrence.
- Figures 6b through 6h expand on step 438 of Figure 6a and further describe several embodiments of a mechanism for calculating the relevance values 152 of occurrences in the help database.
- the relevance values 152 for occurrences in text sections of the one or more documents may be calculated in step 450.
- the relevance values 152 for occurrences in headers of the one or more documents may be calculated.
- a different mechanism may be used to calculate the relevance values 152 for occurrences in headers than the mechanism used to calculate the relevance values 152 for occurrences in text sections.
- Figure 6c expands on step 450 of Figure 6b and further describes one embodiment of a mechanism for calculating relevance values 152 for occurrences in text sections of the one or more documents in the help database.
- the position 146 of the occurrence in the text section may be subtracted from the total words 148 for the text section.
- the words in the text section may be numbered in a sequence from a first word to a last word.
- the first word may be numbered as word 0, and the last word as word (N - 1), where N is the total number of words in the text section.
- the first word may be numbered as word 1, and the last word as word N, where N is the total number of words in the text section.
- the words may be numbered in reverse order, with the first word in the text section being numbered as word N, and the last word as word 1. In this embodiment, steps 460 and 462 may not be performed.
- step 464 the results of step 462, or the results of step 460 in embodiments in which step 482 is not performed, may be divided by the total words 148 for the text section to produce a ratio RI that may represent the relevance value 152 for the text occurrence.
- the word number of the term in the text section may be divided by the total words 148 to produce the ration RI.
- occurrences in headers may be considered more relevant than occurrences in text sections.
- RI may be multiplied by a first scaling factor SI to lower the relevance values of text section occurrences in relation to occurrences in headers.
- a scaling factor SI 0.33 may be applied to RI.
- step 467 the output of step 466, or the output of step 464 in embodiments where step 466 is not performed, may be rounded to a number of significant digits.
- Various rounding methods may be used including rounding up, rounding down, and rounding to the nearest value. For example, if two significant digits are desired, the results may be rounded to produce results in the range (0.01-1.00) inclusive.
- step 468 the results are output as the relevance value 152 for the occurrence in the text section. In one embodiment, the output relevance value 152 may be written to the index table 142.
- the following is an example of applying one embodiment of a mechanism for calculating the relevance value for a text occurrence and is not intended to be limiting in any way.
- the first row of the index table 402 as illustrated in Figure 5 shows that the term "System” appears as the fifth of 54 words in a text section.
- a first scaling factor SI of 0.33 is to be applied and the results rounded to two significant digits.
- Figure 6d expands on step 452 of Figure 6b and further describes one embodiment of a mechanism for calculating relevance values 152 for occurrences in headers of the one or more documents in the help database.
- a first relevance value based on the position of the term in the header may be calculated.
- a second relevance value based on the percentage of the header the term occupies may be calculated.
- the positional and percentage relevance values may be combined.
- occurrences in headers may be considered more relevant than occurrences in text sections.
- the relevance value may be adjusted using a first scaling factor to adjust the relevance value in relation to the relevance values of occurrences in text sections.
- step 477 the output of step 476, or the output of step 474 in embodiments where step 476 is not performed, may be rounded to a number of significant digits substantially similarly to the rounding method used in step 467 of Figure 6c.
- step 478 the results may be output as the relevance value 152 for the occurrence in the header.
- the output relevance value 152 may be written to the index table 142.
- Figure 6e expands on step 470 of Figure 6d, illustrating one embodiment of a mechanism for calculating the positional relevance of an occurrence in a header.
- this mechanism may be substantially similar to the mechanism described in steps 460 to 464 of Figure 6c.
- step 480 of Figure 6e the position 146 of the occurrence in the header may be subtracted from the total words 148 for the occurrence.
- step 482 the results of step 480 may be incremented by one, which may be effective to prevent the relevance value from being zero.
- step 484 the results of step 482, or the results of step 480 in embodiments in which step 482 is not performed, may be divided by the total words 148 for the occurrence to produce a ratio R2 that may represent the relevance value 152 for the header occurrence.
- Figure 6f expands on step 472 of Figure 6d, illustrating one embodiment of a mechanism for calculating the percentage relevance of an occurrence in a header.
- a term may include one or more words.
- Figure 6g expands on step 474 of Figure 6d and illustrates one embodiment of a mechanism for combining the positional relevance as calculated in Figure 6e and the percentage relevance as calculated in Figure 6f for an occurrence in a header.
- the positional relevance may be multiplied by a second scaling factor S2 in step 490.
- the percentage relevance may be multiplied by (1 - S2).
- the percentage relevance may be considered more important than the positional relevance, and thus the percentage relevance may be given a larger weight than the positional relevance.
- S2 may be assigned a value of 0.33, and the positional relevance multiplied by S2.
- the scaled position and percentage relevance values may be added to produce the relevance value for the occurrence in the header.
- occurrences in headers may be considered more relevant than occurrences in text sections.
- Figure 6h expands on step 476 of Figure 6d and illustrates one embodiment of a mechanism for adjusting the header relevance value in relation to the relevance values of occurrences in text sections.
- the scaled header relevance value may then be adjusted by adding the first scaling factor SI to the header relevance value, so that the minimum header relevance value is higher than the maximum text section relevance value.
- Figures 7a through 7c are flow diagrams describing embodiments of a mechanism for providing context- sensitive help in an insurance claims processing system.
- Figure 7a illustrates a high-level view of the entire process, while Figures 7b and 7c give more detail of various steps of Figure 7a.
- a user may initiate processing of an insurance claim in the insurance claims processing system in step 300.
- the insurance claims processing may begin at a first processing step, and may continue through a number of processing steps until the insurance claim has been processed.
- a next processing step may be determined by the user input at a current processing step.
- Each processing step may be displayed to the user in one or more pages on a computer display screen.
- the claims processing system may enter a processing step and display a page for the processing step.
- the context-sensitive help for the page may be invoked.
- Context-sensitive help for each processing step may be unique, although content may appear in the context-sensitive help for two or more processing steps.
- Context-sensitive help may also be unique for each of the one or more pages within a processing step.
- the page for the processing step may be displayed along with the context-sensitive help for the page.
- the context-sensitive help for the page may instead be replace the display of the page for the processing step.
- the displayed page may occupy substantially the entire display screen on the display device.
- the page may be displayed in a window on the display screen.
- the page may be divided into two or more panes, the context-sensitive help may be displayed in one or more panes on the page, and the processing step contents may appear in one or more panes on the page.
- FIG. 7b illustrates step 304 of Figure 7a in more detail.
- the context-sensitive help for the page is invoked.
- items to be searched for in the context-sensitive help system may be determined.
- each page in the insurance claims processing system may have a unique code, which may be referred to as a page ID.
- the page ID for the invoked page may be read.
- the page ID may be stored with information describing the page that is read by the claims processing system prior to displaying the page. The information may describe the format and contents of the page. Alternatively, the page ID may be "hardcoded" into the code of the claims processing system.
- the page may include one or more elements that have associated codes.
- the codes for the one or more elements on the page may also be read.
- the elements on the page may be system-supplied "answers" to questions posed to the user during the claims processing.
- the answers may be classifications for injuries, anatomical regions, etc. used during injury claims processing.
- the text of the elements may be read.
- the insurance claims processing system may search one or more index tables as illustrated in
- Figure 6 for entries including the page ID that may be used to locate help entries for the page in one or more help tables as illustrated in Figures 4 and 5.
- the index table may also be searched for enfries for the elements of the page.
- a code for an element is used to search the one or more index tables for entries.
- the text of the elements is used to search the one or more index tables for entries.
- one or more enfries may be located in the one or more index tables. In one embodiment, there will be at least one entry located for the page ID in the one or more index tables. In one embodiment, if elements of the page have an associated code, there will be at least one enfry located for each code in the one or more index tables. In one embodiment, each entry in the one or more index tables may indicate an occurrence in the one or more documents included in the help database for the insurance claims processing system of the page ID, code, or term included in the index table entry.
- entries may be located in one or more help tables using information from the entries located in the one or more index tables for the page ID and any elements of the page.
- the help tables may be substantially similar to the tables illustrated in Figures 4 and 5.
- each entry in an index table includes an object ID.
- the one or more help tables may be searched for occurrences of the object ID in each located entry.
- the object ID may include information used to determine which help table the object ID is found in. For example, the last two digits of the object ID may indicate if the object ID is an entry for a header table similar to the one illustrated in Figure 4 or for a text table similar to the one illustrated in Figure 5.
- a particular object ID may be included in one or more entries in an index table.
- Figure 7c illustrates step 306 of Figure 7a in more detail.
- the context-sensitive help for the page may be displayed.
- the located help table entries may be ranked by relevance.
- the entries in the index table may include a relevance value.
- the located help table entries may be ranked from highest relevance to lowest relevance. Entries with the same relevance may be ranked by any of several methods, including, but not limited to: alphabetic ranking and order of appearance in the index table.
- the located help table entries may be listed without ranking for relevance.
- any entries found for the page code may be displayed at the top of the list regardless of the relevance ranking of the entry.
- Entries for other codes in the page may then be ranked below the page code entry or entries in order of relevance.
- located enfries may be first ranked on the number of search terms the enfries include.
- a header or text section of a document may include one or more occurrences of the page ID, codes, or terms being searched for.
- Enfries that include more search terms may be ranked higher than entries with fewer search terms.
- the entries within the ranking categories may then be ranked by relevance within the category. Thus, entries with lower relevance, but more search terms, may appear higher in the overall ranking than entries with higher relevance, but fewer search terms.
- information from the located help table entries may be displayed.
- the entries may be displayed in the order of relevance as determined in step 320.
- the help table entries may include portions of text from one or more documents related to insurance claims processing. Some help table enfries may include section headers from the one or more documents. Some help table entries may include text from the bodies of sections of the one or more documents. Some help entries may include glossary information from the one or more documents. Other entries may include text from other portions of the one or more documents.
- the relevance value may also be displayed.
- step 324 information describing the location of the displayed portions of text in the one or more documents may be displayed. This information may allow the user to look up (electronically or manually) located occurrences in the one or more documents.
- the location information may include, but is not limited to: document title, chapter title, and/or number, chapter or section header, section number and/or title, page number, number of occurrences in the section, etc.
- the page display may be split into sections, or panes.
- the information from the located help table entries may be displayed in a first pane; the information describing the location in the one or more documents of displayed portions of text may be displayed in a second pane; and the step information may be displayed in a third pane.
- separate windows may be used to display the information from the located help table enfries, the locations in the one or more documents, and the step information.
- Figure 8 A display screen showing context sensitive help information
- FIG. 8 illustrates one embodiment of a display screen 200 showing multiple panes, wherein two of the panes comprise context sensitive help information for a step and the elements of the step.
- pane 202 may display a step in the processing of an insurance claim.
- One or more step elements 203 may be displayed in pane 202.
- One or more context sensitive help occurrences for the step may be displayed in pane 230.
- One or more context sensitive help occurrences for the elements in the step may also be displayed in pane 230.
- Locations for the context sensitive help occurrences displayed in pane 230 may be displayed in pane 232. In one embodiment, a location may be displayed as a chapter hierarchy of the document in which the occurrence is found.
- Figure 9 A mechanism for searching for insurance claims processing terms
- Figure 9 is a flow diagram illustrating one embodiment of a mechanism for searching for insurance claims processing terms.
- the search mechanism may use the same one or more index tables and one or more help tables as are used in the mechanism for providing context sensitive help as described in
- a user may first initiate processing of an insurance claim in the insurance claims processing system.
- the insurance claims processing may begin at a first processing step, and may continue through a number of processing steps until the insurance claim has been processed.
- a next processing step may be determined by the user input at a current processing step.
- Each processing step may be displayed to the user in one or more pages on a computer display screen.
- the claims processing system may enter a processing step and display a page for the processing step.
- a search interface may be presented to the user on the display screen.
- the search interface may be displayed in response to user action. For example, the user may activate a button or menu item to cause the system to display the search interface.
- the search interface may be presented in any of various forms.
- a text enfry box may be displayed that accepts one or more terms or phrases to be searched for, and a button may be displayed that initiates a search when activated by the user.
- the text entry box may also accept special characters, for example, quotation marks around a group of terms that are to be searched for as a phrase.
- the text entry box may also accept logical operators; for example, an AND operator may be entered between two terms to indicate that help table entries are to be searched for that include both terms.
- the user may enter in the search interface one or more terms to be searched for in the help database for the insurance claims processing system. The user may then initiate the search for the one or more terms.
- the insurance claims processing system may search the one or more index tables for enfries including at least one of the one or more terms.
- one or more entries may be found in the one or more index tables that include at least one of the one or more terms.
- the located entries in the index table may be used to locate help entries in the one or more help tables that include at least one of the one or more terms.
- each entry in an index table includes an object ID.
- the one or more help tables may be searched for occurrences of the object ID from each of the located entries.
- the located help table entries may be ranked by relevance.
- the enfries in the index table may include a relevance value.
- the located help table entries may be ranked from highest relevance to lowest relevance. Entries with the same relevance may be ranked by any of several methods, including, but not limited to: alphabetic ranking and order of appearance in the index table.
- more than one term may be searched for, and located enfries may be first ranked on the number of search terms the entries include. Enfries that include more search terms may be ranked higher than entries with fewer search terms. For example, if the user enters three terms to be searched for, enfries that include all three of the search terms may be ranked first, then entries that include two of the search terms, and finally entries that include just one of the search terms. The entries within the ranking categories may then be ranked by relevance within the category. Thus, enfries with lower relevance, but more search terms, may appear higher in the overall ranking than enfries with higher relevance, but fewer search terms.
- occurrences including more than one of the search terms may be listed once, rather than listing the occurrence for each search term included in the occurrence.
- a relevance value of occurrences including more than one search term may be calculated from the relevance value of each of the terms included in the occurrence. For example, if a search is initiated for the terms "Anatomy" and "Body", and the index table 402 illustrated in Figure 5 is searched, the term “Anatomy” will be located in the third enfry in the table, and the term “Body” in the fourth entry.
- the third and fourth entries have the same object ID 140, indicating that these occurrences are from the same text section.
- only one occurrence may be displayed on the display screen for the text section entry in text table 406 indicated by the object ID 140 of entries two and three in index table 402.
- the relevance value for an occurrence including more than one term may be calculated using the following method:
- the calculated relevance value for the occurrence including the two search terms may then be rounded to 0.27. In one embodiment, the calculated relevance value may then be used in ranking the occurrence including two terms against other occurrences including two terms.
- information from the located help table entries may be displayed. In one embodiment, the entries may be displayed in the order of relevance as determined in step 358.
- the help table entries may include portions of text from one or more documents related to insurance claims processing that include one or more of the one or more search terms. Some help table entries may include section headers from the one or more documents. Some help table entries may include text from the bodies of sections of the one or more documents. Some help entries may include glossary information from the one or more documents. Other entries may include text from other portions of the one or more documents.
- the relevance value may also be displayed.
- step 362 information describing the location of the displayed portions of text in the one or more documents may be displayed. This information may allow the user to look up (electronically or manually) located occurrences in the one or more documents.
- the location information may include, but is not limited to: document title, chapter title, and or number, chapter or section header, section number and/or title, page number, number of occurrences in the section, etc.
- the page display may be split into sections, or panes.
- the information from the located help table enfries may be displayed in a first pane; the information describing the location in the one or more documents of displayed portions of text may be displayed in a second pane; and the step information may be displayed in a third pane.
- separate windows may be used to display the information from the located help table enfries, the locations in the one or more documents, and the step information.
- Figure 10 A display screen showing search results information
- FIG 10 illustrates one embodiment of a display screen 200 showing multiple panes, wherein two of the panes comprise search results information.
- pane 202 may display a page for a step in the processing of an insurance claim.
- the search term "cuboid" 208 has been previously entered by the user, and a search was initiated and completed.
- occurrences of the search terms may be displayed.
- Column 210 of pane 204 may display a location where the term is found. In one embodiment, a portion or all of a text section or a portion or all of a header from a document may be displayed in column 210.
- Column 212 may display a portion or all of a chapter or section title of the document where the occurrence is located.
- Column 214 may list the search term(s) that appear in the occurrence. In this example, only one term 208 was entered. If multiple search terms are entered, then all search terms that appear in a listed occurrence may be listed in column 214.
- Column 216 may display the number of search terms found in the occurrence.
- Column 218 may display the relevance value for the entries.
- all displayed enfries have the same relevance value (1).
- Other embodiments may include more or fewer columns displaying the same or other information about the occurrences.
- not all located entries may be displayed in pane 204.
- An interface item or items may be provided to the user to display other located enfries.
- Interface items may be items displayed graphically on the screen (for example, icons) and selectable using input/output devices such as a mouse, joystick, or arrow keys on a keyboard.
- Interface items may also be keyboard selections such as function keys or key combinations.
- a button may be provided that allows the user to scroll down the list of located entries in pane 204.
- pane 206 information about the location of the occurrences in pane 204 may be displayed.
- Column 220 may display chapter numbers and/or chapter headers from the one or more documents in the help database that include one or more of the located occurrences displayed in pane 204.
- An interface item or items may be provided to allow the user to display enfries not currently displayed in pane 206.
- FIG 11 shows the display screen 200 of Figure 10, with one of the search results panes (pane 204) hidden to provide more display area for claims processing information.
- pane 206 is moved nearer to the top of the display screen than in the display screen illustrated in Figure 10.
- Pane 202 displays the page for a step in the processing of an insurance claim.
- Pane 202 has been expanded to provide more lines for displaying the elements of the step than in the display screen illustrated in Figure 10.
- pane 202 of Figure 11 displays the step element "Injury Description" 220 which was hidden in pane 202 of Figure 10.
- An interface item or items may be provided to the user for hiding or showing one or more panes displaying portions of the search results or context-sensitive help.
- Interface items may be items displayed graphically on the screen (for example, icons) selectable using input/output devices such as a mouse, joystick, or arrow keys on a keyboard. Interface items may also be keyboard selections such as function keys or key combinations. For example, a function key or key combination may be provided to toggle between hiding and showing pane 204.
- the example illustrated in Figure 11 is of a display with search results.
- the hiding and showing of panes as described above may be applied to displays with panes displaying context-sensitive help for a step.
- FIG. Id is a network diagram of an illustrative disfricited computing environment which is suitable for implementing various embodiments.
- the disfricited computing environment may include various server systems 70A and client systems 80A connected by a network 55A. Other networkable devices such as printers 90A may also be connected to the network 55A.
- the servers 70A, clients 80A, and other devices may be geographically dispersed.
- a single computer system may server as both a server and client.
- the network 55A may be a local area network or wide area network, and may include communications links including, but not limited to: Ethernet, token ring, Internet, satellite, wireless, telephone, cable, DSL, and other suitable pathways.
- the Internet includes one or more substantially global networks which are generally accessible by the public (i.e., they are not proprietary or not largely characterized by controlled access).
- Various sources of data on the Internet may be accessed through protocols such as HTTP (HyperText Transport Protocol), HTTPS (Secure HyperText Transport Protocol), FTP (File Transfer Protocol), Telnet, NNTP (Network News Transport Protocol), SMTP (Simple Mail Transfer Protocol), and other suitable protocols. Transmission of data over the Internet is typically achieved through the use of TCP/IP (Transmission Control Protocol/Internet Protocol) packets.
- TCP/IP Transmission Control Protocol/Internet Protocol
- Figures 2aA and 2bA An Insurance Claims Processing Server Computer Architecture and an Insurance Claims Processing Client Computer Architecture
- Figure 2aA is an illustration of an insurance claims processing server computer architecture according to one embodiment.
- Figure 2bA is an illustration of an insurance claims processing client computer architecture according to one embodiment.
- the insurance claims processing server 70A may include a computer system 20aA with a memory 30aA.
- the insurance claims processing client 80A may include a computer system 20bA with a memory 30bA.
- the term "computer system” as used herein generally includes the hardware and software components that in combination allow the execution of computer programs.
- the computer programs may be implemented in software, hardware, or a combination of software and hardware.
- a computer system's hardware generally includes a processor, memory media, and Input/Output (I/O) devices.
- I/O Input/Output
- processor generally describes the logic circuitry that responds to and processes the basic instructions that operate a computer system.
- CPU is used synonymously with “processor” herein.
- memory is used synonymously with “memory medium” herein.
- memory medium is intended to include an installation medium, e.g., a CD-ROM, or floppy disks, a volatile computer system memory such as DRAM, SRAM, EDO RAM, Rambus RAM, etc., or a non-volatile memory such as optical storage or a magnetic medium, e.g., a hard drive.
- the memory medium may comprise other types of memory as well, or combinations thereof.
- the memory medium may be located in a first computer in which the programs are executed, or may be located in a second different computer that connects to the first computer over a network 55. In the latter instance, the second computer provides the program instructions to the first computer for execution.
- the computer system may take various forms, including a personal computer system, mainframe computer system, workstation, network appliance, Internet appliance, personal digital assistant (PDA), television system or other device.
- PDA personal digital assistant
- the term "computer system” can be broadly defined to encompass any device having a processor that executes instructions from a memory medium.
- the memory medium preferably stores a software program or programs for processing insurance claims as described herein.
- the software program(s) may be implemented in any of various ways, including procedure- based techniques, component-based techniques, and/or object-oriented techniques, among others.
- the software programs may be implemented using a rule-based development tool such as PLATINUM AionTM available from Computer Associates International, Inc.
- PLATINUM AionTM may combine business rule and object-oriented technologies to create and maintain complex, knowledge-intensive applications.
- Software developed with PLATINUM AionTM may employ an AionTM programming language for automation of processes which may use hundreds or thousands of business rules from a knowledge base.
- An AionTM inference engine may automatically determine which rules to execute, when, and in what order.
- the software program may be implemented using other technologies, languages, or methodologies, as desired.
- a CPU such as the host CPU, executing code and data from the memory medium includes a means for creating and executing the software program or programs according to the methods, flowcharts, and/or block diagrams described below.
- Various embodiments further include receiving or storing instructions and/or data implemented in accordance with the description herein upon a carrier medium.
- Suitable carrier media include memory media or storage media such as magnetic or optical media, e.g., disk or CD-ROM, as well as transmission media or signals such as electrical, electromagnetic, or digital signals, conveyed via a communication medium such as network 55A and/or a wireless link.
- a computer system's software generally includes at least one operating system, a specialized software program that manages and provides services to other software programs on the computer system.
- Software may also include one or more programs to perform various tasks on the computer system and various forms of data to be used by the operating system or other programs on the computer system.
- the data may include but are not limited to databases, text files, and graphics files.
- a computer system's software generally is stored in non-volatile memory or on an installation medium.
- a program may be copied into a volatile memory when running on the computer system. Data may be read into volatile memory as required by a program.
- a server may be defined as a computer program that, when executed, provides services to other computer programs (referred to as clients) executing in the same or other computer systems.
- the computer system on which a server program is executing may also be referred to as a server, though it may contain a number of server and client programs.
- a server is a program that awaits and fulfills requests from client programs in the same or other computer systems.
- the insurance claims processing server 70A may further include a display device 50aA connected to the computer system 20aA and an insurance database 40A residing on an internal or external storage.
- a “database” may include a collection of information from which a computer program may select a desired piece of data.
- an "insurance database” is used as a synonym for a "database" when included in or coupled to an insurance claims processing system.
- Computer system 20aA includes memory 30aA configured to store computer programs for execution on the computer system 20aA and a cenfral processing unit (or CPU, not shown) configured to execute instructions of computer programs residing on the computer system 20aA.
- Insurance claims processing server software 60A may be stored in the memory 30aA.
- an "insurance claims processing program” 60A or “insurance claims processing software” or “insurance claims processing system” may include a software program which is configured to conduct transactions regarding insurance claims, such as by estimating the value of the insurance claims, for example.
- the insurance claims processing client 80A may further include a display device 50bA connected to the computer system 20bA.
- Computer system 20bA includes memory 30bA configured to store computer programs for execution on the computer system 20bA and a central processing unit (or CPU, not shown) configured to execute instructions of computer programs residing on the computer system 20bA.
- Insurance claims processing client software 68A such as web browser software, may be stored in the memory 30bA.
- the insurance claims processing server 70A may be connected to network 55A.
- the insurance claims processing server software 60A and insurance database 40A may be disfricited among the one or more servers 70A to provide a distributed processing system for insurance claim transactions.
- an insurance claim processing fransaction being processed by the insurance claim processing system may be routed to any server based upon the workload distribution among servers 70A at the time of the transaction.
- Insurance claim processing system servers 70A may be located on a local area network or may be geographically dispersed in a wide area network.
- One or more clients 80A may also be connected to network 55A.
- Clients 80A may reside at one or more claim processing units within the insurance company. In a wide area network, clients 80A may be geographically dispersed. Clients 80A may be used to access one or more insurance claim processing system servers 70A and associated insurance databases 40A. An insurance claim processing employee may use a client 80A to access the insurance claim processing system and execute insurance transactions. An employee may also use a client 80A to enter insurance claim inputs into the insurance claim processing system. As shown in Figure Id, one or more printers 90A may also be connected to network 55A for printing documents associated with insurance claim transactions.
- the insurance claims processing server 70A and client 80A may be used by an Insurance Company for various embodiments of a system and method for processing insurance claims.
- an Insurance Company includes a business organization that provides insurance products and or services to customers. More particularly, the insurance products may pertain to providing insurance coverage for accidents and the trauma-induced bodily injuries that may result due to the accident. Examples of trauma-induced bodily injuries may include, but are not limited to: loss of limb(s); bone fractures; head, neck and or spinal injury, etc.
- a customer may file an insurance claim (IC) with his/her insurance organization to cover medical and other accident-related expenses.
- An IC may utilize a computer-based insurance claim processing system to process insurance claims.
- the processing may include estimating a value, including a bodily injury general damages amount, associated with the filed insurance claim.
- an IC business fransaction may be defined as a service of an IC.
- Examples of business transactions include, but are not limited to: insurance transactions such as filing of claims, payment of claims, application for insurance coverage, and customized benefits, etc.
- Business transactions may also include services related to customers, insurance providers, employers, insurance agents, investigators, etc.
- an IC insurance claim processing includes a series of insfructions executed by a computer system 70A and/or 80A for processing an IC's business transactions.
- a claim processing system may include one or more processing tasks.
- a processing task may include a sequence of one or more processing steps or an ordered list or a structured list of one or more processing steps which associated with the business transaction to be processed by the claim processing system.
- the sequence of steps may be fixed. In another embodiment the sequence of steps may be established dynamically, in real-time. In one embodiment, the sequence of one or more steps may include an initial step, a final step, one or more intermediary steps, etc. In one embodiment, an IC user may select steps to process an insurance claim in a sequential manner. In another embodiment, the IC user may select steps to process an insurance claim in a random or arbitrary manner. Examples of processing steps may include, but are not limited to: receiving an input from a user of the IC insurance claim processing system 70A and or 80A, reading a value from a database, updating a field in a database, displaying the results of a business transaction on a computer screen, etc.
- the insurance claim processing system 70 and/or 80 utilizes object-oriented technology to process insurance claims.
- processing of insurance claims may utilize traditional programming languages and databases to achieve the same result.
- Insurance objects may be defined to represent or model real-world business features of insurance products and services. Examples of insurance objects may include, but are not limited to, objects representing the following: an insurance claim; an accident report; a settlement; an estimated claim; IC service facilities, customers, and employees; business process such as a new insurance application and calculation of a premium; interfaces to external insurance organizations; work tasks such as calculations, decisions, and assignments; temporal objects such as calendars, schedulers, and timers; and elemental data necessary to accomplish work tasks such as medical costs, risk factors, etc.
- An insurance object may be represented on the computer screen 50aA and/or 50bA by a graphical icon or by a display listing the properties of the insurance object in graphic and/or alphanumeric format.
- An insurance claim object may be configured to gather and evaluate data for processing a filed insurance claim and to automatically make decisions about the insurance claim.
- the one or more processing steps associated with the processing of an insurance claim may also be configured as one or more processing step objects.
- a display screen which also may be referred to as a page, may be associated with a processing step.
- the display screen may also be represented as an object.
- Each display screen object may include a property to point to a previous display and another property to point to a next display screen.
- Each property e.g.
- the next display pointer on a display screen object may be changed dynamically by using methods associated with the display screen object.
- One display screen object may serve as the starting point for processing insurance claims.
- the starting point for processing insurance claims may include acquiring an insurance claim identification number from an IC system user.
- a business rule and/or an IC system user input may determine that the insurance claim processing needs the execution of additional steps or tasks to continue the processing of the claim.
- the IC system user may provide inputs to the insurance claims processing server software 60A at any display screen associated with a step included in a Table of Contents.
- the insurance claim processing software may dynamically modify the number of steps and/or the sequence of their execution to complete the claim processing transaction. An IC system user working at a client system 20bA may then iterate through the claim processing steps and arrive at an estimated value for the insurance claim.
- the server software 60A and browser software 68A may provide a graphical user interface to display claims processing related information on display device 50aA and/or 50bA. It may collect user inputs which are associated with insurance claims and entered by using user input devices 52aA and/or 52bA. It may process the user inputs, access an insurance database 40A, use the contents of the insurance database 40A to estimate the insurance claim, and store it in memory 30aA and/or 30bA and/or insurance database 40A.
- the browser 68A may display a value of the estimated insurance claim on display screen 50bA. A user may view the display of the estimated insurance claim on display screen 50bA and may interactively make modifications, additions, and deletions to the estimated insurance claim.
- Systems 20aA and 20bA may also include one or more user input devices 52aA and 52bA, such as a keyboard, for entering data and commands into the insurance claim program 60A. It may also include one or more cursor control devices 54aA and 54bA such as a mouse for using a cursor to modify an insurance claim viewed on display screen 50aA and/or 50bA. In response to the updating of the estimated insurance claim, the insurance claim server software 60A may store the updated insurance claim in the insurance database 40A.
- Figure 3aA An Insurance Claims Processing Server Software Architecture
- Figure 3aA is an illustration of an insurance claims processing server software 60A architecture for a single client according to one embodiment.
- the server software 60A may include an insurance processing rules engine 61 A.
- a "rules engine” may include an expert system which is operable to produce an output as a function of a plurality of rules.
- a rules engine in one embodiment, may include an expert computer system which utilizes and builds a knowledge base developed in the form of business rules and/or formulas to assist the user in decision-making.
- the rules engine 61 A is operable to generate insurance claim assessment questions to be displayed to a user during an insurance claim consultation session.
- the rules engine 61 A may also be operable to estimate a value of an insurance claim as a function of insurance claim assessment data entered by a user in response to the insurance claim assessment questions.
- the insurance claim may include a bodily injury claim
- the insurance claim assessment questions may include bodily injury claim assessment questions
- the insurance claim assessment data may include bodily injuries and treatments thereof.
- the rules engine 61 A is capable of processing rules associated with assessing bodily injury damages claims.
- a rules engine 61A comprises an expert computer system which utilizes and builds a knowledge base developed in the form of business rules to assist the user in decision-making. It allows the insurance companies to capture the knowledge base of their experts by defining business rules. Once created, the expertise may be used in processing many transactions, including assessing bodily injury damages claims.
- the business rules enable claim-processing professionals to be assisted by industry experts to evaluate legal, medical, insurance conditions before arriving at a valuation of an insurance claim.
- the rules engine 61 A may be implemented and executed on various computing platforms such as personal computers and mainframes.
- the rules engine 61 A may comprise a rules engine executable file on these platforms.
- the rules engine may be accessed through various user interfaces, such as a graphical user interface for a rules engine 61 A which is executable on a MicrosoftTM WindowsTM-based server 70A.
- the rules engine 61 A may be developed using a commercial rule-based development tool such as PLATINUM AionTM, which is available from Computer Associates International, Inc.
- the rules may be customized to meet the requirements of a particular insurance company.
- Business rules often referred to simply as rules, may include executable computer program instructions.
- the rules include computer commands or logical insfructions to achieve a certain function.
- rules may guide an assessment or estimate of bodily injury general damages.
- Each rule in one embodiment, includes a premise followed by one or more resulting actions.
- a business rule may state 'If patient requires hospitalization after emergency care freatment then the trauma severity level should be classified as major'.
- the premise is 'patient requires hospitalization after emergency care treatment'.
- the resulting action is 'trauma severity level should be classified as major'.
- the insurance claim processing server 70A may include several thousand business rules. The rules may be executed or fired, under the control of the insurance claim processing software, based on certain events, user inputs, etc.
- the insurance claim processing server software 60A may generate a consultation report which summarizes an assessment and/or estimate of the bodily injuries claim.
- the rules may be stored in and retrieved from an insurance database 40A.
- the type of information stored and/or retrieved may include, but not be limited to, business objects, tables, rules, software source code, executable software, etc.
- the database may include a relational database.
- the database 40 may include an object-oriented database.
- the insurance claims processing server software 60A may include adapter software 62A which may provide access to the rules engine for one or more other computer-based applications or subsystems, such as an internet information server 64A.
- the adapter software 62A provides an application programming interface (API) to the rules engine 61 A.
- API application programming interface
- the adapter software 62A is discussed in greater detail with reference to Figure 4A.
- the insurance claims processing server software 60A may include a web server such as an internet information server (IIS) 64A.
- IIS internet information server
- a "web server" includes a system for supplying clients with access to web pages, such as by sending the pages to clients via an appropriate protocol.
- a web server may also be operable to generate the web pages dynamically.
- a "web page” includes a block of information which is configured to be displayed by a web browser 68A.
- a "web browser” or “browser software” includes software which is configured to receive and display web pages. Examples of web browsers include Internet ExplorerTM available from MicrosoftTM Corporation and Netscape NavigatorTM available from Netscape Communications Corporation.
- a web page is configured to be displayed in a single window in a web browser, wherein the window may be scrolled to view off- screen elements of the web page.
- Web pages may include various combinations of text, graphics, audio content, video content, and other multimedia content.
- a web page is often encoded in a language such as HTML (HyperText Markup Language).
- Web pages may be viewed in a browser on the same computer system on which the server 64A or web pages reside. Web pages may also be transmitted to a client computer system over a network 55A, such as via the HyperText Transport Protocol (HTTP) 56. Where the network 55A includes the Internet, the web pages may be fransmitted via standard protocols such as TCP/IP.
- HTTP HyperText Transport Protocol
- the internet information server (IIS) 64A may include a commercial product such as MicrosoftTM Internet Information Server available from MicrosoftTM Corporation.
- the server 64A may include an active server pages (ASP) controller 65A which is operable to generate web pages dynamically.
- ASP active server pages
- the web pages delivered by the internet information server 64A may be built in real time by the ASP controller 65A upon a request for a page by a browser 68A.
- Active server pages may include dynamic web pages which are created, for example, by blending HTML and server-side scripting. Active server pages may be dynamically constructed to include insurance claim assessment questions and other user interface elements by starting from a template.
- the web server 64A may be configured to generate a plurality of web pages comprising the insurance claim assessment questions.
- the web browser 68A may then be configured to display the plurality of web pages comprising the insurance claim assessment questions.
- the web browser 68A may then be configured to receive insurance claim assessment data entered by a user in response to the insurance claim assessment questions during an insurance claim consultation session and send the insurance claim assessment data to the web server 64A.
- the web server 64A is further configured to receive the insurance claim assessment data from the web browser 68A and send the insurance claim assessment data to the rules engine 61A.
- the rules engine 61 A may be further configured to generate and send the estimate of the value of the insurance claim to the web browser 68A through the web server 64A.
- the web browser 68A may be further configured to display the estimate of the value of the insurance claim received from the rules engine 61 A through the web server 68 A.
- the web server 64A and web browser 68A may be located on separate computer systems which are communicatively coupled through a network 55A.- In another embodiment, the web server 64A and web browser 68A may be located and executed on a single computer system.
- Figure 3bA An Insurance Claims Processing Server Software Architecture
- HTTP is considered to be a stateless internet access protocol.
- each request from a web browser 68A to a web server 64A is essentially a request-response interaction. Therefore, when a web browser 68A requests a web page, for example, the web server 64A may complete the interaction between the two by sending the page to the browser 68A.
- a consultation session conducted by a user through a web browser 68A which communicates with the rules engine 61A may include many successive interactions through the web server 64A. It would tend to be inefficient to start a rules engine executable file for each of the many interactions that may take place during a single consultation session.
- FIG. 3bA is an illustration of an insurance claims processing server software architecture for multiple clients 68aA, 68bA, 68cA according to one embodiment.
- a rules engine may be executed or started for that particular user and then "held" in an IIS session for that user.
- Figure 3bA illustrates an example including three browsers 68aA, 68bA, 68cA which correspond to and communicate with respective rules engines 61aA, 61bA, 61cA.
- Each IIS session may include an individual ASP controller 65aA, 65bA, 65cA.
- Each rules engine 61aA, 61bA, 61cA may therefore be linked to its corresponding ASP controller 65aA, 65bA, 65cA through individual adapter software 62aA, 62bA, 62cA.
- Figure 4A Adapter Software
- FIG 4A is an illustration of adapter software between a rules engine and a web server according to one embodiment.
- the adapter software 62A may include one or more components which permit software such as applications or other components to communicate with the rules engine 61A.
- the adapter software may provide methods to start and communicate with a rules engine executable file 61 A.
- a component is a software object which includes definitions of method of communication for that software object.
- components are implemented according to a component architecture specification such as the Component Object Model (COM) or Distributed Component Object Model (DCOM) promulgated by MicrosoftTM.
- COM Component Object Model
- DCOM Distributed Component Object Model
- the component architecture specification for COM enables applications and components which follow the specification to pass data, commands, and other information back and forth.
- a COM interface may be said to "wrap" an object, server, or other piece of software if that COM interface defines methods of interaction or communication with that object, server, or piece of software.
- the adapter software 62A may include one or more COM components 63bA and a dynamic link library (DLL) 63aA.
- a DLL may include a library of executable functions or data that can be used by an application such as a MicrosoftTM WindowsTM-based application.
- a DLL provides one or more particular functions, and a program may access those functions by creating either a static or dynamic link to the DLL. A static link remains constant during program execution, while a dynamic link is created by the program as needed.
- the DLL 63aA may provide a lower-level interface to the functions and methods of the rules engine 61A.
- the DLL 63aA may take advantage of published protocols for accessing a rules engine implemented with a commercial system such as PLATINUM AionTM.
- the DLL 63aA may be provided by the supplier of the commercial system for developing a rules engine.
- the COM component(s) 63bA may then provide a higher-level interface to the DLL 63aA, which in turn may provide an interface to the rules engine 61A.
- the "business intelligence" may be confined to the rules engine 61 A and DLL 63aA, and the COM component(s) 63bA may expose an interface which permits other pieces of software to convert data, requests, and other parameters to function calls provided by the DLL 63aA.
- the COM component(s) 63bA may include methods including, but not limited to, the following: setListParameter, setSingleParameter, getNextMessage, lastErrorMessage, sendMessage, terminateSession, fransactMessage, getListParameter, getSingleParameter, startServerSession, and startRefsysSession. Appropriate parameters may be defined for each method.
- Figure 5A Transmission of Data Between a Web Server and a Web Browser
- FIG. 5A illustrates the transmission of data between a web server and a web browser according to one embodiment.
- Each ASP controller 65A may be a web-specific COM component or components that may run in a process space associated with the IIS 64A. These components may be operable to start, stop, and send data 69A (such as insurance claim consultation data entered in response to insurance claim consultation questions) to the rules engine 61 A. These components may also be operable to receive data (such as insurance claim consultation questions and elements of the user interface) from the rules engine 61 A for inclusion in one or more web pages 67 A. Generally, these components are configured to translate data between HTML on the IIS 64A side and the interface exposed by COM components 63bA on the other side.
- These components may include functionality such as data validation (e.g., determining if datatypes of entered data are valid).
- the components may also ensure that the state of the interactions or "conversation" between a rules engine and a browser is preserved, as discussed in greater detail with respect to Figure 4bA and Figure 9A.
- the ASP controller 65A may include at least two COM components: one which handles interactions between a web browser 68 and the rules engine executable file, and another which handles interactions between the web browser 68A and a reference system or help system executable file.
- the reference system executable file may provide the user with detailed assistance in conducting an insurance claim consultation session.
- the COM component(s) for accessing the reference system may include methods including, but not limited to, the following: addedRefsysID, initializeContentsGraphs, startSessionlfNecessary, MemberOftrueHierarchylds, lastSearchText, lastSelectedChapterObjectld, terminateSession, getFirstMessage, pageHasError, getListParameter, chapterWasSelected, writeRefsysContents, writeContextContents, writeSearchResults, writeHelpTextAsHTML, contextHelpWasSelected, isSessionStarted, searchHifWasSelected, mergeLostBoys, searchWasSelected, and iisSessionld.
- Appropriate parameters may be defined for each method.
- the COM component(s) for accessing the rules engine 61A may include methods including, but not limited to, the following: terminateSession, startSessionlfNecessary, writePredisplayHtml, handleExitProcessing, getFirstMessage, pageToShow, errorMessage, pageHasError, pageWasPosted, doPageTransaction, getSingleParameter, getListParameter, getListParameterNoTrim, debuglt, formatAdsDate, hasSaveButton, hasBackButton, hasNextButton, hasContentsButton, hasCommentsButton, hasUnknownButton, hasReportButton, claimKeyFormat, statusMessage, iisSessionld, and isSessionStarted.
- Appropriate parameters may be defined for each method.
- FIG. 6A Browser-based User Interface
- Figure 6A illustrates an example of a browser-based user interface for the insurance claims processing system according to one embodiment.
- the browser window 100A may be displayed in a display device 50bA coupled to a client computer system.
- a web browser includes a set of standard navigation commands. As shown in Figure 6A, examples of these commands may include "back" 110A to move to the previously visited page, "forward" 112A to move to the page previously visited before selecting "back,” “reload” 114A to obtain and redisplay the current page from the server, and "home” 116A to move to a previously designated home page.
- These standard navigation commands may be made available to the user as menu items and/or as buttons or other GUI elements.
- a button may be "pushed," often by a mouse click or appropriate keyboard key, to initiate the command supplied by the button.
- the browser page 104A may include an active server page or other HTML-encoded page supplied by the web server 64A.
- the page 104A may include one or more specialized navigation commands. In one embodiment, these specialized navigation commands may be displayed as buttons or other GUI elements.
- the specialized navigation commands may include, for example, "save” 120A to save the status of a consultation session, "help” 122A to access a reference system for insurance claim processing, "exit” 124A to safely exit the insurance claim consultation session, "back” 130A to safely move to a previous page of the insurance claim consultation session, and "reset” 132A to reset the proper state of the browser page 104A.
- the reset command is further described with reference to Figure 9A.
- Insurance claim assessment data and/or insurance claim assessment questions 140A may also be displayed in the browser page 104A. For example, for a given step in the insurance claim consultation session, one or more questions may be asked regarding bodily injuries and/or treatments thereof.
- a set of acceptable answers i.e., insurance claim assessment data
- the set of acceptable answers may be dynamically generated by the rules engine based upon answers to previous questions.
- Figure 7 A A Method of Developing a Web-Based Insurance Claims Processing System
- Figure 7A is a flowchart illustrating a method of developing a web-based insurance claims processing system according to one embodiment. The steps shown in Figure 7A may be performed in various orders according to various embodiments.
- a rules engine may be developed or otherwise provided. As discussed with reference to Figure 3aA, the rules engine may be configured to estimate a value of an insurance claim as a function of insurance claim assessment data entered by a user in response to insurance claim assessment questions.
- the rules engine may be wrapped with a component interface in accordance with a component architecture specification.
- Component interfaces are discussed in greater detail with reference to Figures 4A and 5A.
- the component interface may include one or more definitions of methods of communication or other access to the rules engine, such as by a web server.
- the component architecture specification may include a Component Object Model (COM) specification.
- COM Component Object Model
- a web server may be provided, wherein the web server which is configured to generate a plurality of web pages which are viewable by a web browser.
- the methods of communication in the component interfaces may be operable to transmit the insurance claim assessment data from the web server to the rules engine and operable to transmit the insurance claim assessment questions from the rules engine to the web server.
- Figure 8A A Method of Hosting a Web-Based Insurance Claims Processing System
- FIG. 8 A is a flowchart illustrating a method of hosting a web-based insurance claims processing server with various pricing models according to one embodiment.
- an insurance claim processing server may be hosted.
- hosting may include installing, maintaining, and/or otherwise providing client access to a server.
- the insurance claim processing server may be configured to estimate a value of an insurance claim as a function of insurance claim assessment data entered by a user during an insurance claim consultation session.
- the insurance claim processing server may include a rules engine and a web server, and the client software may include a web browser.
- the web server may be operable to generate web pages and receive responses and requests from the web browser to enable communication between the rules engine and the web browser.
- client software such as a web browser may be provided to a user such as an insurance company.
- the client software may include commercial, off-the-shelf web browser software which may already be in use by an insurance company and its employees who seek to access to the insurance claim processing server.
- the client software may be operable to receive the insurance claim assessment data entered by the user and send the insurance claim assessment data across a network to the insurance claim processing server.
- the insurance claim processing server may be operable to send the estimate of the value of the insurance claim to the client software across the network.
- the network may include the Internet.
- the user may be charged for access to the insurance claim processing server through client software according to a pricing model.
- Various pricing models may be used with various embodiments of the hosting system and method.
- the pricing model may include a fee for each of a plurality of insurance claim consultation sessions conducted by the user.
- the pricing model may include a fee for each fixed period of access time of access by the user to the insurance claim processing server through the client software.
- the fixed period of access time may include an hourly multiple, a weekly multiple, a monthly multiple, a yearly multiple, or a multiple of minutes.
- the pricing model may include a fee which varies directly with an amount of time spent accessing the insurance claim consultation session through the client software.
- the user may include an insurance organization having a particular size, and the pricing model varies according to the size of the user.
- the size of the user may include a function of a quantity of employees of the user, a function of a revenue of the user over a period of time, and/or a function of a quantity of consultation sessions conducted by the user over a period of time.
- the pricing model may include a pricing discount given to the user after a particular quantity of insurance claim consultation sessions conducted by the user in a particular period of time.
- the insurance claim consultation session may include one or more insurance claim consultation transactions, and the pricing model may include a fee for each of a plurality of insurance claim consultation transactions conducted by the user during one or more insurance claim consultation sessions.
- the method may further include charging additional users for access to the insurance claim processing server through client software according to a same or different pricing model.
- Figure 9A A Method of Using a Reset Button for a Web-Based Insurance Claims Processing System
- Figure 9A is a flowchart illustrating a method of using a reset button provided by a web-based interface to a web-based insurance claims processing server according to one embodiment.
- a first page of insurance claim assessment data may be displayed in a browser program executing on a computer system.
- the browser program may include a web browser program which is operable to read and display web pages.
- the computer system which executes the browser program may include a client computer system which is communicatively coupled to a server computer system.
- the server computer system may be operable to generate and send a plurality of pages of insurance claim assessment data to the client computer system.
- one of the specialized navigation commands such as a forward command, may be selected to advance to a second page of insurance claim assessment data.
- the user may advance to the second page by hitting "return” or otherwise instructing the insurance claim processing server to provide a next page in a consultation session.
- the second page of insurance claim assessment data including the specialized navigation commands, may be displayed in the browser.
- one of the standard navigation commands such as the "back" command or button available in a toolbar or menu in a web browser, may be selected to move back to the first page of insurance claim assessment data. The first page of insurance claim assessment data may then be redisplayed.
- the user may attempt to perform an insurance claim assessment task on the redisplayed first page of insurance claim assessment data. For example, the user may attempt to save a status of an insurance claim consultation by pressing a "save" button in the specialized buttons.
- the insurance claim consultation may include an interactive determination of an estimate of a value of an insurance claim through the entry of insurance claim assessment data in response to insurance claim assessment questions.
- the insurance claim assessment task may include selecting one of the other specialized navigation buttons provided as the user interface by insurance claim processing server.
- the insurance claim assessment task may also include entering new or modifying existing insurance claim assessment data.
- Insurance claim assessment data may include information relevant to an estimate of a value of an insurance claim, such as bodily injuries and treatments thereof.
- the insurance claim assessment data may include bodily injury claim assessment data, and the insurance claim assessment task may include a bodily injury claim assessment task.
- the state of the "conversation" between the browser and the insurance claim processing server may be preserved by a COM component 66A, as discussed with reference to Figure 5A.
- a navigation error may be generated as a result of the attempting to perform an insurance claim assessment task on the first page, when the second page is the "correct" page in the conversation.
- a navigation error message may be generated and displayed to the user as a result of the generating the navigation error.
- the navigation error message may include an instruction to select a reset command, wherein the reset command is one of the specialized navigation commands.
- step 314A the user may select the reset command after viewing the navigation error message.
- the insurance claim processing server may automatically perform a reset function without user intervention as a result of the navigation error.
- step 316A the second page (i.e., the "correct" page) of insurance claim assessment data may then be redisplayed. The user may then perform a second insurance claim assessment task on the redisplayed second page of insurance claim assessment data.
- Figure 2B Generating a table of contents for an insurance claim according to one embodiment.
- the user of an insurance claims processing system 10 may use a client system 80 to initially configure, or set up, all the display screens associated with the insurance claims processing business process.
- a display screen may be associated with a step included in processing insurance claims.
- the business process for processing the insurance claims may utilize an applicable subset of all display screens. The inclusion or exclusion of a display screen in a table of contents display screen may be based on business rules, user inputs, etc.
- the business process for processing the insurance claims may utilize all display screens.
- each of the display screens involves defining the properties of the display screen object such as previous display screen pointer, next display screen pointer, source for data displayed, etc. Additionally, each display screen configuration may require specifying one or more user input fields, defining business rules associated with the processing of data for the display screen, etc.
- the configuration of the display screen object may include invocation of methods such as Load_Screen, Display_Screen, Validate_Screen, Save_Screen, Process_Screen, etc.
- a registry is maintained for all display screen objects.
- Figure 6B shows a few examples of the properties and methods associated with a display screen object according to one embodiment.
- the table of contents is a display screen, window, or subset of a screen which shows a roadmap, including one or more applicable steps, for processing an insurance claim.
- Figure 5B is a screen shot showing one embodiment of a TOC display screen.
- the table of contents includes one or more steps required to process insurance claims. Each step has an associated display screen.
- the table of contents display screen and each step display screen may be configured as an object. The number of steps included in the table of contents may be dynamically and automatically modified in real-time based on business rules, user inputs, etc.
- the display screen object for the table of contents includes one or more display screen objects, representing intermediary steps, selected from all display screen objects.
- Each display screen object may include a property, such as Display_In_TOC, which enables the display screen object and corresponding step to be included in the TOC.
- the user of the insurance claims processing system 10 may initiate the insurance claim processing by specifying a claim number. The claim number may then be received by the insurance claim processing system 10.
- a determination may be made as to whether the specified claim number exists in the insurance claims processing system 10, such as in the insurance database 40. If it is determined that the specified claim number is a new claim number, then program confrol is passed on to step 130B. If a matching record is found in the insurance database 40 for the specified claim number, then program control is passed on to step 150B.
- the IC user may set up the claim definition data for a new claim.
- the setting up of the claim definition data may include providing user inputs through one or more display screens, as defined in the regisfry for the claim definition data display screen object.
- Examples of claim definition data provided by the IC user may include, but are not limited to, claimant demographic data such as name, age, address, phone number, etc., injury code information such as neck, spine, arm, etc., and treatment code information such as emergency care, hospital, outpatient, physical therapy, etc.
- the insurance claim processing software 60 may dynamically modify the properties of the display screen objects by using appropriate methods.
- the IC user may submit a request to display the table of contents screen.
- the insurance claim processing software will generate a request to display the table of contents screen in step 140B.
- a request may be made to display the table of contents screen in step 140B.
- the insurance claim processing software executes a function or method to generate the TOC display screen.
- executing the function to generate the table of contents may include invoking a Create_TOC_Enfry method for the TOC display screen object.
- Figure 3B describes in further detail a flowchart for a function or method to generate the table of contents.
- the newly generated TOC display is sent to the display screen 50 for display to the IC user.
- Figure 3B illustrates one embodiment of a program or method to build a table of contents display.
- the insurance claim processing software executes a Create_TOC_Entry method for all display screen objects which have a "True" entry in a Display_In_TOC property field.
- step 154B the insurance claim processing software 60 verifies that each display screen object has been validated, such as by checking that a Valid_Screen method has been invoked successfully.
- the Function Re_Evaluate_All is called prior to displaying the TOC and it validates all pages. This validation process may choose to remove screens from the process because they are no longer appropriate.
- step 156B a determination is made as to whether the previous screen pointer for the current display screen object is present or is not present. If no previous screen pointer is present, then that display screen object is included in the TOC display screen.
- step 158B if a previous screen pointer is present and if the source of data property field indicates that the data was entered by a user, then the display screen object is included in the TOC display screen.
- step 159B the list of display screen objects included with the TOC is returned to the calling function.
- the screens are then displayed based on individual logic in their Create_TOC_Enfry function.
- FIG. 4B Using a table of contents for processing an insurance claim Figure 4B is a flowchart which further illustrates the use of a table of contents for processing an insurance claim according to one embodiment.
- the processing of the insurance claim my be initiated by initiating a first step, wherein the processing of the insurance claim includes a plurality of steps.
- the steps may include screens displayed on the display device 50 coupled to a computer system 10.
- the insurance claim may include a bodily injury claim, and processing the insurance claim to estimate the value of the insurance claim may include processing the bodily injury claim to estimate a bodily injury general damages value.
- the steps may include steps for entry of information relevant to the estimate of the value of the insurance claim.
- the information may include, for example, bodily injury treatment information and/or bodily injury damages information.
- the first step may include the user entering a claim identification number as discussed with reference to Figure 2B.
- entering the claim identification number may already have taken place, and the "first step" may actually include a step such as the enfry of an injury code or treatment code during the consultation session.
- step 510B one or more of the steps in the processing of the insurance claim may be proceeded through to arrive at an intermediary step.
- the user may enter injury and/or treatment data in response to questions presented in one or more steps.
- the intermediary step may then be displayed.
- the intermediary step is any step between the first and final steps in the plurality of steps of processing the insurance claim. Proceeding through the one or more of the steps in the processing of the insurance claim may include entering information relevant to the estimate of the value of the insurance claim in the one or more of the steps.
- the entered information may be stored in a memory.
- a table of contents may be displayed upon the entry of an appropriate command by the user. For example, the user may select a GUI element such as a button or hit a designated keyboard key to display the table of contents.
- the table of contents may be generated according to the method discussed with reference to Figure 3B.
- the table of contents may include an ordered list of the steps associated with the processing of the insurance claim, and the ordered list of steps may include the first step, the intermediary step, and any steps in between the first step and the intermediary step. Therefore, the table of contents may essentially show a "roadmap" of the business process for processing insurance claims.
- the ordered list of steps may be dynamically modifiable in response to the entry of information in a step. In other words, steps may be added to or deleted from said dynamically modifiable ordered list of steps in response to the enfry of information.
- the table of contents may be shown as a display screen, window, or other subset of a screen.
- step 550B the user may be permitted to select one of the steps from the ordered list of steps associated with the processing of the insurance claim in the table of contents.
- step 560B the selected step may then be displayed in response to the user selecting the selected step in the table of contents.
- step 570B in one embodiment, the entered information in the selected step may be modified and stored after selecting the step in the table of contents.
- the intermediary step may be redisplayed upon entry of an appropriate command by the user.
- the user may go back to the previously displayed step, either through the table of contents or through entry of a suitable "back" command.
- the processing of the insurance claim may be continued after redisplaying the intermediary step by permitting the user to enter additional information relevant to the estimate of the value of the insurance claim.
- the ordered list of steps in the table of contents may include a final step.
- the final step may be selected at any time from the table of contents.
- the final step may include a consultation report concerning an estimate of the value of the insurance claim.
- the consultation report may include information related to the estimate of the value of the insurance claim, wherein the estimate may be calculated based on information entered in the first step and in any steps in between the first step and the intermediary step.
- all or substantially all of the steps associated with using the table of contents may be executed within a single session of an application program executing on a computer system. Therefore, the user of the system need not exit the system and restart from the beginning in order to go back to a previously encountered step.
- Figure 5B An exemplary table of contents screen display
- Figure 5B is a screen shot which illustrates an example of a table of contents display screen according to one embodiment.
- Figure 6B Exemplary properties and methods of a display screen object
- Figure 6B illustrates exemplary properties and methods associated with a display screen object according to one embodiment.
- Figure 2C Identifying critical factors affecting the fair estimate value, included in an insurance claim consultation report.
- Figure 2C is a flowchart illustrating a method for identifying one or more contributing factors relevant to an estimate of a value of an insurance claim according to one embodiment.
- the user of an insurance claims processing system 10 may use a client system 80 to initially configure, define, set up the insurance claim processing system 10. This includes installing and executing the insurance claim processing software or program 60 as well as the insurance database 40.
- the insurance database 40 may include data for various insurance codes related to injuries, freatments.
- insurance codes may include injury codes and freatment codes.
- step 1 IOC one or more insurance codes which are relevant to the value of the insurance claim may be specified in an insurance claims processing program executable on a computer system. Each insurance code may be considered a contributing factor to the estimated value of the insurance claim.
- These insurance codes may be entered by a user during a consultation session in which a claimant reports his or her injuries and/or treatments for a particular insurance claim.
- a claim number for the insurance claim may be specified, and the one or more insurance codes may be associated with the claim number.
- the insurance codes may include one or more injury codes, wherein each injury code specifies a bodily injury incurred by the claimant.
- the insurance codes may include one or more treatment codes, wherein each treatment code specifies a freatment for at least one of the bodily injuries incurred by the claimant.
- a consultation report typically includes an estimated value or range of estimates values for each bodily injury claim.
- the insurance claims processing system In determining the range of fair estimate value, the insurance claims processing system typically uses contributing factor values, along with regional factors such as cost of living, etc. to arrive at a monetary estimate.
- Confributing factor values due to bodily injury are generally directly proportional to the level of trauma experienced during and after the bodily injury.
- the insurance claims processing system may be operable to calculate a numeric value for an insurance code wherein, for example, the claimant is in a coma and is on life support system because of a bodily injury.
- Treatment received for the bodily injury such as hospitalization, surgery, physical therapy, etc. may contribute to decrease the trauma and hence may result in a decrease of the estimated value.
- the confributing factors associated with the treatment code may therefore have a negative value.
- one or more contributing factor values may be determined.
- Each of the contributing factor values corresponds to one of the insurance codes, and each of the contributing factor values measures an estimated impact of the corresponding insurance code on the value of the insurance claim.
- the insurance claim may include a bodily injury claim, and the contributing factor values may be relevant to an estimate of a bodily injury general damages value of the bodily injury claim.
- Each of the one or more contributing factor values may include a numeric value.
- determining the one or more contributing factor values may include calculating the one or more confributing factor values as a function of one or more business rules.
- a rules engine or other expert system may be configured to calculate dynamically the amount that each insurance code adds to or subtracts from the estimate of the value of the insurance claim.
- This amount contributed by one insurance code may be dependent on the amounts contributed by other specified insurance codes.
- the expert system may be developed using the PLATINUM AionTM rule-based development environment available from Computer Associates International, Inc. In one embodiment, this determination of the contributing factor values may take place after substantially all of the insurance codes have been entered and when a consultation report is desired to be displayed.
- each of the one or more insurance codes and the corresponding contributing factor values may be stored in a table.
- An example of such a table is illusfrated in Figure 3C.
- Figure 3C shows a table with a column for the insurance codes (e.g., injury codes and treatment codes) 330C and a column for contributing factor values 350. The values shown are for purposes of example only and are not intended to be limiting.
- the table may include one or more rows, wherein each row of the table includes one of the insurance codes and the corresponding contributing factor value.
- the table may be implemented as a table in a relational database.
- the table may be implemented in accordance with object-oriented techniques of software design.
- the table may be sorted by the confributing factor values to generate a sorted table of contributing factor values 350C and corresponding insurance codes 330C.
- the table may be sorted by contributing factor value 350C in ascending or descending order.
- a set of contributing factors (i.e., insurance codes) from the sorted table which meet one or more selection criteria may be identified and reported.
- the set of contributing factors may be included in a consultation report which may be printed and/or displayed on a display device.
- the selection criteria may include a selection of the largest positive of the one or more confributing factor values up to a certain quantity, such as five.
- identifying and reporting the set of confributing factors from the sorted table may include identifying and reporting a sorted set of the largest confributing factor values up to the certain quantity.
- each contributing factor value in the sorted set of the largest positive contributing factor values adds to the estimate of the value of the insurance claim.
- the selection criteria may include the largest negative of the one or more contributing factor values up to a certain quantity, such as five. Therefore, identifying and reporting the set of contributing factors from the sorted table may include identifying and reporting a sorted set of the largest negative contributing factor values up to the certain quantity. Each contributing factor value in the sorted set of the largest negative contributing factor values subtracts from the estimate of the value of the insurance claim.
- Figure 2D A flow chart to transform formulas data to formulas for assessing bodily injury damages claims according to one embodiment
- Figure 2D illustrates one embodiment of a method to transform formula data to formulas for assessing bodily injury damages claims according to one embodiment.
- the user or the administrator of the insurance claim processing system 20 provides a rules engine, which is capable of processing rules and operating on formulas associated with assessing bodily injury damages claims.
- a "rules engine” may include an expert system which is operable to produce an output as a function of a plurality of rules.
- a rules engine in one embodiment, may include an expert computer system which utilizes and builds a knowledge base developed in the form of business rules and/or formulas to assist the user in decision-making. It allows the insurance companies to capture the knowledge base of their experts by defining business rules and formulas.
- the expertise may be used in processing many transactions, including assessing bodily injury damages claims.
- the business rules and formulas enable claim-processing professionals to be assisted by industry experts to evaluate legal, medical, insurance conditions during the valuation of an insurance claim.
- the rules engine may be developed using a commercial rule-based development tool such as PLATINUM AionTM, which is available from Computer Associates International, Inc.
- Business rules are executable computer program insfructions.
- the business rules may invoke, operate or execute formulas to calculate trauma severity values associated with personal bodily injury claims.
- the formulas include computer commands or logical insfructions to achieve a certain mathematical function, i.e., assess trauma severity value for a spinal injury.
- Each formula in one embodiment, may include a function operating on one or more inputs to compute one or more outputs.
- the formulas may include a plurality of functions operating on one or more inputs to compute one or more outputs.
- the function may be mathematical such as add, subtract, divide, etc.
- the function may be based on custom algorithms, for example an algorithm to calculate phantom pain associated with bodily injuries.
- the insurance claim processing system may include several formula types, wherein each formula may be specified by a unique function. The formulas may be invoked, operated, executed or fired, under the control of the business rules. Only the pertinent formulas, i.e., a subset of all the available formulas, are typically be selected and executed for processing a specific bodily injury damages claim.
- step HOD the user or the administrator of the insurance claim processing system 20 provides a database 40, which is external to the rules engine, and is capable of storing and/or retrieving information associated with insurance claim processing.
- the term "external" means that the database is separate from the rules engine.
- the type of information stored and or retrieved may include, but not be limited to, business objects, tables, formulas, software source code, executable software, etc.
- the database may be relational.
- the database 40 may be an object-oriented database.
- the database 40 may include a plurality of tables, which may be accessed by a translator program, also referred to as an application program, to transform, create, generate, or instantiate the data stored in the tables into formulas.
- the database may include a plurality of knowledge bases often storing knowledge data in the form of tables.
- Knowledge-bases may include, but not be limited to, data, tables, program insfructions, business rules, objects, etc.
- the data stored in the knowledge bases may also be in the form of objects.
- the translator program may transform data stored in tables into static instances of an object class.
- the formula data table shown by way of example in Figure 3aD includes data structured in a tabular format, i.e., a table with several rows and columns.
- the Formulas class of objects may include static instances wherein each static instance is a direct representation of a row of data in the formula data table.
- the formula data table may include all the relevant information necessary to transform each row of the formula data table into a static instance of the Formula object class.
- the entire set of business formulas may be grouped or classified into a plurality of formula types.
- Each formula may have a common construction style, e.g., a function operating on one or more inputs to compute one or more outputs.
- there may be several hundred pre-defined formulas types.
- New formula types to meet user requirement may also be created and added to the existing formula type list or table.
- Data included in the example formulas data table shown in Figure 3aD may typically include information necessary to create a static instance of the Formula object class.
- the formula data may include a plurality of enfries in a table in a database, and the formula data may include a formula identifier 300D, a sequence number 310D, a section description, a page identifier, a prompt identifier, an answer identifier, a mathematical function or operation 320D, a numeric value 330D, and other suitable elements.
- the translator program initiates the transformation of data stored in the formula data table to formulas i.e. the creation of static instances of the Formula object class, by reading the formula data.
- methods such as KBOpen and ControlLoad may be used to open and load the formulas data table. Every knowledge base table has a corresponding object class name in the insurance claim-processing program 60.
- the formula data knowledge base table may have a corresponding formula object class. The contents of each row are read one row at a time.
- step 140D data entry in each column of the formulas data table is used to transform, or create an instance of the formula class object in the formulas knowledge base.
- the ControlLoad function determines which set of instances of the Formula class must first be deleted using Deletelnstances ('Formulas') and recreated via Class(Formulas).Load function.
- the instance of the formulas class in the formulas knowledge-base may be invoked, operated, or executed by the business rules by using the calculate method with FormulalD and the sequence number as the parameters.
- the calculate method gathers all of the static instances with a specified FormulalD along with a sequence number. The calculate method then interprets the operations and controls how the formula is executed. The resulting output value is used to calculate the trauma severity value.
- Steps 130D and 140D may be repeated, in one embodiment, to read all rows of the formulas data table and transform the data to as many instances of the formulas class.
- the insurance claim processing software 60 may compute a trauma severity value applicable to a specific bodily injury claim consultation transaction, and print a consultation report, which summarizes an assessment or estimate of the bodily injury general damages claim.
- the task of updating, modifying, or revising the formulas may be simplified.
- the user or the administrator of the insurance claim processing system 20 may update the data enfries stored in the formulas data table.
- the instances of the formulas class may be automatically updated to reflect the changes.
- the task of customizing of formulas to meet specific user requirements may also be simplified.
- the customizing of formula data in response to business requirements results in customized formulas.
- the user or the administrator of the insurance claim processing system 20 may add a new instance of the formulas class and update the database 40.
- steps 130D and 140D the formulas may be automatically customized to reflect the new changes.
- Figure 3aD Formula Data Table in one embodiment
- Figure 3aD illustrate the tabular structure of the formula data table according to one embodiment.
- the table may comprise fewer or more columns.
- the formula data table may be implemented in any number of ways, such as a relational database, in a variety of commercially available database management systems.
- the formula data table may have as many rows as may be supported by the database management system in which it is implemented.
- the formula data table may be accessed (e.g., searched, written to, read from, etc.) through a programming interface or standard access mechanism (e.g., SQL) which is supported by the database management system in which the formula data table is implemented.
- a programming interface or standard access mechanism e.g., SQL
- Figure 2E A flow chart to transform rules data to rules for assessing bodily injury damages claims according to one embodiment
- Figure 2E illustrates one embodiment of a method to fransform rules data to rules for assessing bodily injury damages claims according to one embodiment.
- the user or the administrator of the insurance claim processing system 20 provides a rules engine, which is capable of processing rules associated with assessing bodily injury damages claims.
- the rules engine may be included as part of the insurance claims processing system 10, such as the insurance claims processing program 60, as shown in Figure la.
- a "rules engine” may include an expert system which is operable to produce an output as a function of a plurality of rules.
- a rules engine in one embodiment, may include an expert computer system which utilizes and builds a knowledge base developed in the form of business rules and/or formulas to assist the user in decision-making.
- the business rules enable claim-processing professionals to be assisted by industry experts to evaluate legal, medical, insurance conditions before arriving at a valuation of an insurance claim.
- the rules engine may be developed using a commercial rule-based development tool such as PLATINUM AionTM, which is available from Computer Associates International, Inc.
- Rules are executable computer program instructions.
- the rules include computer commands or logical insfructions to achieve a certain function.
- rules may guide an assessment or estimate of bodily injury general damages.
- Each rule in one embodiment, includes a premise followed by one or more resulting actions.
- a business rule may state 'If patient requires hospitalization after emergency care treatment then the trauma severity level should be classified as major'.
- the premise is 'patient requires hospitalization after emergency care treatment'.
- the resulting action is 'trauma severity level should be classified as major'.
- the insurance claim processing system may include several thousand business rules.
- the rules may be executed or fired, under the control of the insurance claim processing software, based on certain events, user inputs, etc. Only pertinent rules, i.e., a subset of all the available rules, are typically selected and executed for processing a specific bodily injury damages claim.
- step HOE the user or the administrator of the insurance claim processing system 20 provides a database 40, which is external to the rules engine, and is capable of storing and/or retrieving information associated with insurance claim processing.
- the term "external" means that the database is separate from the rules engine.
- the type of information stored and/or retrieved may include, but not be limited to, business objects, tables, rules, software source code, executable software, etc.
- the database may be relational.
- the database 40 may be an object-oriented database.
- the database 40 may include a plurality of tables, often referred to as knowledge- bases, which may be accessed by an translator program or other application program to transform or create or generate the data stored in the tables into rules.
- the application program may transform data stored in tables into static instances of an object class.
- the rules data table as shown by way of example in Figure 3aE includes data structured in a tabular format, i.e., a table with several rows and columns. The rules data table includes all the relevant information necessary to fransform each row of the rules data table into an equivalent business rule.
- the entire set of business rules may be grouped or classified into a plurality of rule styles.
- Each rule style may have a common construction style, i.e., the syntax for the rule premise and the resulting rule action may be common. In one embodiment, there may be several hundred pre-defined rules styles. New rule styles to meet user requirement may also be created and added to the existing rule style list or table.
- Data included in the rules data table shown in Figure 3a may typically include information necessary to construct the rule premise and the resulting one or more rule actions.
- the rules data table shown in Figure 3a may include, but not be limited to, columns such as an injury code 300E, an adjustment type, an adjustment amount 310E, a rule style 330E, a rule name 320E, etc.
- LineText table may store lines or other elements of text which may be used to generate the rules.
- the Template table may include information which may be used by the application program to read each row of data from the rules data table and fransform, create or generate the rules data into a rule.
- every rule style may have an entry in the Template table.
- the location to store the transformed rule, the name of the rules data table, the name of the rule style, an identifier for the line text, etc. may also be included in the Template table, in one embodiment.
- the application program initiates the transformation of data stored in the rules data table to rules by reading the rules data.
- the KB Open and the ControlLoad methods may be used to open and load the rules data knowledge base table.
- every knowledge base table has a corresponding object class name in the insurance claim-processing program 60. The contents of each row are read one at a time.
- step 140E data enfries in each column of the rules data table are used to fransform, create, or construct the rules. Enfries for columns like rules style and rules name in the rules data table may be used as a key to find a matching record in the Template table. Other data stored in the columns of the rules data may be used to build the rule premise and/or the resulting one or more rules action.
- the specific syntax used to construct the rule is specified in the Template for a given rule style 330E and a rule name 320E. For example, in one embodiment, rule style RS000 and rule name RN000 may specify:
- the text string corresponding to the above transformed rule may be stored in the Line_Text 370E field of the LineText table shown in Figure 3cE using Line_TextID 360E as a location reference obtained from the Template table shown in Figure 3bE.
- Steps 130E and 140E may be repeated, in one embodiment, to read all rows of the rules data knowledge base table and transform the data to a plurality of rules.
- the insurance claim processing software 60 may print a consultation report, which summarizes an assessment for the bodily injuries claim.
- the task of updating, modifying or revising of rules may be simplified.
- the user or the administrator of the insurance claim processing system 20 may update the data enfries stored in the rules data table.
- the rules may be automatically updated to reflect the changes.
- the task of customizing of rules to meet specific user requirements may also be simplified.
- the user or the administrator of the insurance claim processing system 20 may add a new entry to the rule style and rule name table and update the database 40.
- the rules may be automatically customized to reflect the new changes.
- Figures 3aE, 3bE and 3cE Rules data Table, Template Table and Line Text Table in one embodiment
- Figures 3aE, 3bE and 3cE illustrate the tabular structure of the Rules data Table, Template Table and Line Text Table according to one embodiment. Only four columns are illusfrated for each of the table. In one embodiment, each of the tables may comprise more or fewer columns. In one embodiment, the tables may be implemented in any number of ways, such as a relational database, in a variety of commercially available database management systems. The tables may have as many rows as may be supported by the database management system in which they are implemented. The tables may be accessed (e.g., searched, written to, read from, etc.) through a programming interface or standard access mechanism (e.g., SQL) which is supported by the database management system in which the tables are implemented.
- the data shown in the various tables in Figures 3aE, 3bE, and 3cE are for purposes of example only and are not intended to be limiting.
- Figure 4E A block diagram of the transformation of rules data to rules for assessing bodily injury damages according to one embodiment
- an embodiment of the transformation of rules data to rules may include a knowledge table
- the knowledge table may be a rules data table as shown in Figure 3aE.
- the knowledge table 400E includes data necessary to transform, or build, or create, or define, or generate rules based on a specified rule structure.
- the transformation method 420E (as discussed in greater detail with reference to Figure 2E) orchestrates the combining of the data from the knowledge table 400E and the rule syntax specified in the Template table 440E.
- the transformation method 420E may save the rule as text in an associated knowledge base or insurance database.
- Figure 2F Generating a message for an insurance claim processing system
- Figure 2F is a flowchart illustrating the generation of a message for processing an insurance claim by an insurance claim processing system, according to one embodiment.
- the user of insurance claims processing system 10 may use a client system 80 to initially configure, set up, install and store the software associated with the insurance claims processing system, including all the messages.
- a message may be defined by a message code and a corresponding message text and both the message code as well as the message text stored in a message table.
- a message code and a corresponding message text and both the message code as well as the message text stored in a message table.
- the message code may further include a message section 300F and a message code identifier 310F.
- the combination of a specific message section and a specific message code identifier uniquely specifies or selects the message text 320F from the message table.
- the initial configuration may include specifying or selecting a country and/or a language for the installation. In one embodiment, the selection of a language and/or a country may automatically select a corresponding message text stored in a database. In another embodiment, the user may modify the message text during the installation process.
- step 110F the application program software executing in the insurance claims processing system 10 may initiate a request to display a message. This may be in response to the execution of code in another portion of the application program software, or in response to a previous user input and/or in response to the execution of a business rule.
- step 120F the request to retrieve message text is processed further.
- the request may be further processed by another portion of the application program software by invoking the GetMessageText method of the Message object, and including values for MsgSectionln and MsgCodeln arguments associated with the GetMessageText method.
- the processing of the request may include executing software of a subroutine function to retrieve a corresponding message text for a given message code passed along by the requesting program as an input.
- the message text may be retrieved from a database, in one embodiment or from an object repository in another embodiment.
- step 130F the message text corresponding to a specified message code is received from step 120F.
- step 140F the requested message text is sent to the requesting program for display.
- Figure 3F Using a messages table for an insurance claim processing system
- FIG. 3F is a flowchart illustrating a method of using a messages table associated with processing an insurance claim according to one embodiment.
- an insurance claims processing program may generate a request to display a message, wherein the request may include a requested message code.
- Each message code may include a sequence of alphanumeric values, wherein each sequence is unique relative to the other sequences.
- each message code may include a message section and a message code identifier, as further illustrated in Figure 4F.
- a messages table in a database may be searched for a matching entry which matches the requested message code.
- the table may store a plurality of enfries including the matching entry, wherein each entry in the table may include a message code and a corresponding message text.
- the database may be implemented, for example, as a relational database or an object-oriented database.
- the matching entry may be retrieved from the table in response to said searching the table for the matching enfry which matches the requested message code, wherein the matching enfry comprises a matching message text.
- the matching message text corresponding to the requested message code may be displayed by the insurance claims processing program on a display device coupled to a computer system. The message text may be configured to assist a user in processing an insurance claim using the insurance claims processing program.
- the message text of each entry in the table may be specified during an installation of the insurance claims processing program on a computer system and/or during an installation of the table on a computer system.
- the message text of each entry in the table in the database may be updated by reinstalling the table on the computer system without re-installing the insurance claims processing program on the computer system.
- the message text of one or more entries in the table may be customized for a particular insurance organization during an installation of the insurance claims processing program on a computer system. Additionally, the message text of one or more entries in the table may be localized for use in a particular geographical location.
- the insurance claim may include a bodily injury claim, and processing the insurance
- claim may include processing the bodily injury claim to estimate a bodily injury general damages value.
- the requested message text may include information relevant to an estimate of a value of the insurance claim.
- the requested message code may include an injury code which identifies a specific bodily injury, and the requested message text may include a name of the specific bodily injury.
- the requested message code may include a treatment code which identifies a specific injury treatment, and the requested message text may include a name of the specific injury treatment.
- Figure 4F An example of a messages table
- Figure 4F is an exemplary diagram of a messages table in a database according to one embodiment.
- the messages table may include columns such as message section 300F, message code identifier 31 OF, and message text 320F.
- the messages table may be implemented in any number of ways, such as a relational database, in a variety of commercially available database management systems.
- the messages table may have as many rows as may be supported by the database management system in which it is implemented.
- the messages table may be accessed (e.g., searched, written to, read from, etc.) through a programming interface or standard access mechanism (e.g., SQL) which is supported by the database management system in which the messages table is implemented.
- a programming interface or standard access mechanism e.g., SQL
Landscapes
- Business, Economics & Management (AREA)
- Accounting & Taxation (AREA)
- Finance (AREA)
- Engineering & Computer Science (AREA)
- Development Economics (AREA)
- Economics (AREA)
- Marketing (AREA)
- Strategic Management (AREA)
- Technology Law (AREA)
- Physics & Mathematics (AREA)
- General Business, Economics & Management (AREA)
- General Physics & Mathematics (AREA)
- Theoretical Computer Science (AREA)
- Financial Or Insurance-Related Operations Such As Payment And Settlement (AREA)
Description
Claims
Applications Claiming Priority (3)
Application Number | Priority Date | Filing Date | Title |
---|---|---|---|
US21408900P | 2000-06-23 | 2000-06-23 | |
US214089P | 2000-06-23 | ||
PCT/US2001/020030 WO2002001460A2 (en) | 2000-06-23 | 2001-06-21 | System and method for processing insurance claims |
Publications (1)
Publication Number | Publication Date |
---|---|
EP1303825A1 true EP1303825A1 (en) | 2003-04-23 |
Family
ID=22797735
Family Applications (1)
Application Number | Title | Priority Date | Filing Date |
---|---|---|---|
EP01946676A Withdrawn EP1303825A1 (en) | 2000-06-23 | 2001-06-21 | System and method for processing insurance claims |
Country Status (4)
Country | Link |
---|---|
EP (1) | EP1303825A1 (en) |
AU (1) | AU2001268693A1 (en) |
CA (1) | CA2414587C (en) |
WO (1) | WO2002001460A2 (en) |
Families Citing this family (4)
Publication number | Priority date | Publication date | Assignee | Title |
---|---|---|---|---|
US9536266B2 (en) * | 2012-08-01 | 2017-01-03 | Sap Se | Fact checker engine |
CN109509102B (en) * | 2018-08-14 | 2023-04-11 | 深圳平安医疗健康科技服务有限公司 | Claims settlement decision method, device, computer equipment and storage medium |
CN109472705B (en) * | 2018-09-26 | 2024-04-26 | 平安健康保险股份有限公司 | Method, system, computer device and storage medium for claim settlement |
US20230105093A1 (en) * | 2021-10-01 | 2023-04-06 | CorVel Corporation | Systems and methods for claim processing |
Citations (4)
Publication number | Priority date | Publication date | Assignee | Title |
---|---|---|---|---|
US5446885A (en) * | 1992-05-15 | 1995-08-29 | International Business Machines Corporation | Event driven management information system with rule-based applications structure stored in a relational database |
WO1997049049A1 (en) * | 1996-06-19 | 1997-12-24 | Pegasystems Inc. | Rules bases and methods of access thereof |
WO1999044111A2 (en) * | 1998-02-27 | 1999-09-02 | Onehealthbank.Com, Inc. | Point of service third party financial management vehicle for the healthcare industry |
WO2000036544A1 (en) * | 1998-12-18 | 2000-06-22 | Frog Design, Inc. | System and method for configuring a product |
-
2001
- 2001-06-21 WO PCT/US2001/020030 patent/WO2002001460A2/en active Search and Examination
- 2001-06-21 EP EP01946676A patent/EP1303825A1/en not_active Withdrawn
- 2001-06-21 AU AU2001268693A patent/AU2001268693A1/en not_active Abandoned
- 2001-06-21 CA CA2414587A patent/CA2414587C/en not_active Expired - Lifetime
Patent Citations (4)
Publication number | Priority date | Publication date | Assignee | Title |
---|---|---|---|---|
US5446885A (en) * | 1992-05-15 | 1995-08-29 | International Business Machines Corporation | Event driven management information system with rule-based applications structure stored in a relational database |
WO1997049049A1 (en) * | 1996-06-19 | 1997-12-24 | Pegasystems Inc. | Rules bases and methods of access thereof |
WO1999044111A2 (en) * | 1998-02-27 | 1999-09-02 | Onehealthbank.Com, Inc. | Point of service third party financial management vehicle for the healthcare industry |
WO2000036544A1 (en) * | 1998-12-18 | 2000-06-22 | Frog Design, Inc. | System and method for configuring a product |
Also Published As
Publication number | Publication date |
---|---|
AU2001268693A1 (en) | 2002-01-08 |
CA2414587A1 (en) | 2002-01-03 |
WO2002001460A2 (en) | 2002-01-03 |
CA2414587C (en) | 2013-12-31 |
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