WO1996024103A1 - Claim processing system - Google Patents

Claim processing system

Info

Publication number
WO1996024103A1
WO1996024103A1 PCT/AU1996/000052 AU9600052W WO9624103A1 WO 1996024103 A1 WO1996024103 A1 WO 1996024103A1 AU 9600052 W AU9600052 W AU 9600052W WO 9624103 A1 WO9624103 A1 WO 9624103A1
Authority
WO
Grant status
Application
Patent type
Prior art keywords
system
algorithm
system according
insurance
lodged
Prior art date
Application number
PCT/AU1996/000052
Other languages
French (fr)
Inventor
Peter Carroll
David L. Gadiel
Original Assignee
Peter Carroll Pty. Limited
Health Care Intelligence Pty. Limited
Priority date (The priority date 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 date listed.)
Filing date
Publication date

Links

Classifications

    • GPHYSICS
    • G06COMPUTING; CALCULATING; COUNTING
    • G06QDATA PROCESSING SYSTEMS OR METHODS, SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL, SUPERVISORY OR FORECASTING PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL, SUPERVISORY OR FORECASTING PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q40/00Finance; Insurance; Tax strategies; Processing of corporate or income taxes
    • G06Q40/02Banking, e.g. interest calculation, credit approval, mortgages, home banking or on-line banking
    • GPHYSICS
    • G06COMPUTING; CALCULATING; COUNTING
    • G06FELECTRIC DIGITAL DATA PROCESSING
    • G06F19/00Digital computing or data processing equipment or methods, specially adapted for specific applications
    • GPHYSICS
    • G06COMPUTING; CALCULATING; COUNTING
    • G06QDATA PROCESSING SYSTEMS OR METHODS, SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL, SUPERVISORY OR FORECASTING PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL, SUPERVISORY OR FORECASTING PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q20/00Payment architectures, schemes or protocols
    • G06Q20/04Payment circuits
    • GPHYSICS
    • G06COMPUTING; CALCULATING; COUNTING
    • G06QDATA PROCESSING SYSTEMS OR METHODS, SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL, SUPERVISORY OR FORECASTING PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL, SUPERVISORY OR FORECASTING PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q20/00Payment architectures, schemes or protocols
    • G06Q20/08Payment architectures
    • G06Q20/10Payment architectures specially adapted for electronic funds transfer [EFT] systems; specially adapted for home banking systems
    • GPHYSICS
    • G07CHECKING-DEVICES
    • G07FCOIN-FREED OR LIKE APPARATUS
    • G07F7/00Mechanisms actuated by objects other than coins to free or to actuate vending, hiring, coin or paper currency dispensing or refunding apparatus
    • G07F7/08Mechanisms actuated by objects other than coins to free or to actuate vending, hiring, coin or paper currency dispensing or refunding apparatus by coded identity card or credit card or other personal identification means
    • G07F7/10Mechanisms actuated by objects other than coins to free or to actuate vending, hiring, coin or paper currency dispensing or refunding apparatus by coded identity card or credit card or other personal identification means together with a coded signal, e.g. in the form of personal identification information, like personal identification number [PIN] or biometric data

Abstract

A claim processing system (10) releases funds to a user (11) who communicates a claim over a telephone network (13) to data processor (14) adapted to execute algorithm (15). When the requirements of the algorithm have been met, the claim will be paid into the bank account (16) of the user (11).

Description

CLAIM PROCESSING SYSTEM

TECHNICAL FIELD

This invention relates to a claim processing system which provides conditional release of funds and, more particularly, to an automated claim processing system. BACKGROUND ART

Present methods of payment of insurance claims and the like require significant human intervention on the part of the insurer or its agents.

SUMMARY OF THE INVENTION

According to one aspect of the invention there is provided a system for release of funds to a system user subsequent to satisfaction of queries defined by an algorithm.

Preferably the queries include one or more of a security code query, user details query and release-specific details query.

The algorithm may reside on a computer or like data processing device and the funds may be released to a bank account or equivalent by electronic means.

In one particular form of the invention, the security code query requires an algorithmic combination of three sub-queries. Preferably, the sub-queries include claimant PIN, service codes and algorithm key (as defined below).

In one particular form of the invention, the system relates to release of funds relating to insurance claims with system user being an insured person or claimant. In this particular embodiment of the invention, the algorithm includes:-

(i) checks of the validity of the information

transmitted,

(ii) access and review of any relevant claims history,

(iii) validation of entitlement to claim,

(iv) calculation of the amount of the claim,

(v) subject to validity and security procedures,

automatic payment of the claim by electronic funds transfer to a specified bank account or by other approved method, and

(vi) preparation of audit reports.

Preferably, the system user responds to the queries via a telephone, computer terminal or similar device which is in electronic communication with the computer on which the algorithm resides.

In a further broad form of the invention, there is provided a system to facilitate a process whereby insurance claims for hospital, medical and other health expenses are remotely and electronically lodged by claimants through the telephone system, such that an insurance carrier is able, by invoking an algorithm:-

(i) to assess correctly the benefit entitlement

attributable to the service for which the expense was incurred; and

(ii) to validate claims so lodged and assessed by

preventing them from being incorrectly accepted; and to remit electronically (or by other means) any moneys payable in respect of claims so lodged, assessed and validated.

For claims made in person by customers at branch office counters or claims lodged through the postal system, the algorithms may also be invoked by insurance branch office employees or at head office points of customer service (see below).

BRIEF DESCRIPTION OF THE DRAWINGS

In order that the invention may be more readily

understood and put into practical effect reference will now be made to the accompanying drawings in which:-

Fig. 1 is a block diagram of a system for

releasing funds according to one embodiment of the invention;

Fig. 2 is a logic flow diagram of the system of

Fig. 1; and

Fig. 3 is a block diagram of a preferred

combination of sub-queries to form a code usable with the system of Fig. 1.

MODES FOR CARRYING OUT THE INVENTION

Fig. 1 shows a system 10 for release of funds to a system user 11 which includes a telephone or personal computer 12 adapted for electronic communication over telephone network 13 to data processor 14 adapted to execute algorithm 15. Data processor 14 is also in

electronic communication via telephone network 13 with a bank account 16 of user 11. User 11 may respond to queries generated by algorithm 15 on data processor 14 and communicated to his personal computer 12 over the telephone network 13 by using his keyboard 17.

In one specific example, with reference to Figs. 2 and

3, the data processor 14 is operated by an insurer and user 11 is a policyholder of the insurer.

The user or policy holder can make a claim on the insurer by following the steps outlined in Fig. 2, namely establishing communication via keyboard or telephone dialler with the insurance companies computer 14 in

accordance with box 20, thereafter entering via the

keyboard or telephone dialler (for example telephone touchphone pad) code 21, policyholder details 22 and claim details 23.

These entries are prompted for by algorithm 15

communicating over telephone network 13 with the telephone or computer 12 comprising a security code query in order to prompt for code 21, a user details query in order to prompt for policyholder details 22 and release-specific details query in order to prompt for claim details 23.

Once the answers to the queries have been provided to computer 14, algorithm 15 performs an assessment of the claim with reference to a policyholder database, look-up tables and the like whereby it checks the validity of the information transmitted, reviews relevant claims history in accordance with box 24 of Fig. 2. Ultimately, when algorithm 15 is satisfied, it will validate and approve the insurance claim as per box 25 whereafter the approved claim amount can be transferred electronically to a bank account 16 of the user

(policyholder) 11.

In order to improve security, code 21 can itself be derived from a sub-algorithm of algorithm 15 involving a user response to at least three sub-queries 31, 32, 33 comprising a user specific PIN number 31, service codes 32 provided by service providers and an algorithm key 33 (see Fig. 3).

The codes (referred to as #CODE#) 21 are designed to reduce the susceptibility of the process to abuse, in combination with other security measures. #CODE# 21 can combine elements supplied by each of the policyholder, the service provider and the insurer so that only people with access to all three elements can readily process claims.

Policyholders may be issued Personal Identification Numbers (PINs) 31 which will be used to identify them uniquely and confidentially to thh system. PINs will not be readily accessible to employees of the insurer or of the service provider. Where claims are made by the service providers, authorisation may be required from the

policyholders for the services claimed.

In another application of the invention a point of response may be a front counter of a branch office or head office of an insurance company where bar codes are scanned either directly or through the corporate network into a data processor by insurance company staff using a scanning device rather than by the claimant using the telephone system.

Service providers may be issued with service codes 32 by the insurer, in various forms (for example, as coupons, adhesive labels, or embodied in computer programs) for attachment to the record of service and/or payment given to the policyholder to enable them to process the claim automatically. Service codes will not be readily

accessible to policyholders, except for valid claims.

Insurers may issue additional coding material which will act as a key 33 to "unlock" the algorithm which will process claims. There will be procedures to ensure these keys are not readily usable for obtaining payments except for valid claims.

Other security elements, including restriction of access to and periodic variation of codes, and limits on the size, timing and form of claim payments, may be used to complement the security measures.

The invention allows claims to be made by any

authorised person. Claimants authorised for this purpose may include:-

(i) policyholders in respect of insured services for themselves, their families or their employees, (ii) service providers such as hospitals, medical

practitioners and dentists, (in the case of health insurance) or plumbers, electricians, builders, repairers and similar (in the case of household and motor insurance) for insured services they have supplied to policyholders. Although the invention may have wide application in insurance generally, the benefits will be greatest where there is a high frequency of small claims and where claims assessment relies on the routine application of eligibility rules rather than human judgements and negotiations between the claimant and the insurer.

Initially, the most likely applications will be medical and health insurance claims, particularly for ancillary benefits, and for minor household and motor insurance claims.

In preferred forms, the invention offers the

opportunity for increased efficiency, such as lower costs, higher speed and greater accuracy, of claims processing, and it allows claimants to process their claims at a time they choose from a location remote from the insurer.

The above describes only some embodiments of the present invention and modifications, obvious to those skilled in the art, can be made thereto without departing from the scope and ambit of the invention.

INDUSTRIAL APPLICABILITY

The invention may be applied to the payment of health and other insurance claims.

Claims

1. A system for release of funds to a system user
subsequent to satisfaction of queries defined by an algorithm.
2. A system according to claim 1 wherein the queries include one or more of a security code query, user details query and release-specific details query.
3. A system according to claim 1 wherein the algorithm resides on a computer or like data processing device and the funds are released to a bank account or equivalent by electronic means.
4. A system according to claim 2 wherein the security code query requires an algorithmic combination of three subqueries.
5. A system according to claim 4 wherein the sub-queries include claimant PIN, service codes and an algorithm key (as hereinbefore defined).
6. A system according to claim 1 which relates to release of funds relating to insurance claims with system user being an insured person or claimant, and wherein the algorithm includes:- (i) checks of the validity of the information
transmitted,
(ii) access and review of any relevant claims history, (iii) validation of entitlement to claim,
(iv) calculation of the amount of the claim,
(v) subject to validity and security procedures,
automatic payment of the claim by electronic funds transfer to a specified bank account or by other approved method, and
(vi) preparation of audit reports.
7. A system according to claim 6 wherein the system user responds to the queries via a telephone, computer terminal or similar device which is in electronic communication with the computer on which the algorithm resides.
8. A system to facilitate a process whereby insurance claims for hospital, medical and other health expenses are remotely and electronically lodged by claimants through the telephone system, such that an insurance carrier is able, by invoking an algorithm:-
(i) to assess correctly the benefit entitlement
attributable to the service for which the expense was incurred; and
(ii) to validate claims so lodged and assessed by
preventing them from being incorrectly accepted; and to remit electronically (or by other means) any moneys payable in respect of claims so lodged, assessed and validated.
9. A system according to claim 8 wherein the claims are made in person by customers at branch office counters or are lodged through the postal system and wherein the algorithms may also be invoked by insurance branch office employees or at head office points of customer service.
PCT/AU1996/000052 1995-02-02 1996-02-02 Claim processing system WO1996024103A1 (en)

Priority Applications (2)

Application Number Priority Date Filing Date Title
AUPN0863 1995-02-02
AUPN086395 1995-02-02

Publications (1)

Publication Number Publication Date
WO1996024103A1 true true WO1996024103A1 (en) 1996-08-08

Family

ID=3785223

Family Applications (1)

Application Number Title Priority Date Filing Date
PCT/AU1996/000052 WO1996024103A1 (en) 1995-02-02 1996-02-02 Claim processing system

Country Status (1)

Country Link
WO (1) WO1996024103A1 (en)

Cited By (4)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
EP0825544A1 (en) * 1996-08-23 1998-02-25 The Pharmacy Fund Inc. Computerized healthcare accounts receivable purchasing, collections, securitization and management system
EP1220131A2 (en) * 2000-12-07 2002-07-03 ScalePoint Technologies Limited System and method of providing a replacement of a replaceable product of an insurance claim
EP1329827A1 (en) * 2000-10-18 2003-07-23 ARKRAY, Inc. Input assisting system
US9984415B2 (en) 2009-09-24 2018-05-29 Guidewire Software, Inc. Method and apparatus for pricing insurance policies

Citations (7)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
GB1407660A (en) * 1972-04-12 1975-09-24 Docutel Corp Banking machine
US4750121A (en) * 1985-10-03 1988-06-07 Halley Gustavo M Pension benefits system
EP0297780A2 (en) * 1987-06-30 1989-01-04 Northern Group Services Inc Insurance administration system
US5163098A (en) * 1990-09-06 1992-11-10 Dahbura Abbud S System for preventing fraudulent use of credit card
EP0527639A2 (en) * 1991-08-14 1993-02-17 U.S. Order, Inc. Home financial transaction system
WO1993008546A1 (en) * 1991-10-23 1993-04-29 Lino Bonavitacola Electronic system for automatically transferring a percentage of a sum, spent on purchases in shops involved in the scheme, to an insurance policy in the purchaser's name
EP0583896A2 (en) * 1992-07-28 1994-02-23 Fujitsu Limited Automatic cash transaction apparatus

Patent Citations (7)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
GB1407660A (en) * 1972-04-12 1975-09-24 Docutel Corp Banking machine
US4750121A (en) * 1985-10-03 1988-06-07 Halley Gustavo M Pension benefits system
EP0297780A2 (en) * 1987-06-30 1989-01-04 Northern Group Services Inc Insurance administration system
US5163098A (en) * 1990-09-06 1992-11-10 Dahbura Abbud S System for preventing fraudulent use of credit card
EP0527639A2 (en) * 1991-08-14 1993-02-17 U.S. Order, Inc. Home financial transaction system
WO1993008546A1 (en) * 1991-10-23 1993-04-29 Lino Bonavitacola Electronic system for automatically transferring a percentage of a sum, spent on purchases in shops involved in the scheme, to an insurance policy in the purchaser's name
EP0583896A2 (en) * 1992-07-28 1994-02-23 Fujitsu Limited Automatic cash transaction apparatus

Cited By (6)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
EP0825544A1 (en) * 1996-08-23 1998-02-25 The Pharmacy Fund Inc. Computerized healthcare accounts receivable purchasing, collections, securitization and management system
EP1329827A1 (en) * 2000-10-18 2003-07-23 ARKRAY, Inc. Input assisting system
EP1329827A4 (en) * 2000-10-18 2006-08-30 Arkray Inc Input assisting system
EP1220131A2 (en) * 2000-12-07 2002-07-03 ScalePoint Technologies Limited System and method of providing a replacement of a replaceable product of an insurance claim
EP1220131A3 (en) * 2000-12-07 2003-06-11 ScalePoint Technologies Limited System and method of providing a replacement of a replaceable product of an insurance claim
US9984415B2 (en) 2009-09-24 2018-05-29 Guidewire Software, Inc. Method and apparatus for pricing insurance policies

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