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  Medical Claims Processing System

Custom Project Name

Medical Claims Processing System

Customer (country)

Young software development company specializing in EDI (Electronic Data Interchange) and NFS (National Standard Format) B2B systems.

Business Case

One of the critical activities in a medical institution is to fill out medical claims, which are then sent to insurance companies. Medical claim contains patient's diagnosis code(s) - so called ICD codes, and codes of procedures, services or supplies assigned to treat the patient - CPT codes. Total patient's charge is based on ICD and CPT codes, so it's extremely important to fill them out correctly. However due to large number of those codes (many thousands) there is a high risk for errors. Insurance companies rejected and sent back to medical institution the invalid claims, and a lot of extra man/hours had to be spent on revising patient's medical history to find a proper ICD or CPT code.

Therefore client's company decided to offer middle-man service to doctors and medical institutions, which would help medical institutions to minimize the number of errors and to reduce claim turnaround time.

Solution

Novosoft offered to develop a total web-based B2B solution for validating medical claims with ICD and CPT codes. Novosoft solution provided entry of claims for doctors/clerks using simple upload web interface, no download or installation is required on doctor's side. For added convenience, the solution accepts claims in ASCI format (as a result of 'Print to file' feature) as well as NSF files. Novosoft develops state-of-art parsing of ACSI files, which can be customized to respond to specific medical institution's needs.

Uploaded claims are validated on the fly, and if any invalid codes are found, doctor/clerk can correct the claim immediately through the web-interface. The solution provides electronic transfer of completed claims to insurance companies, and if the company does not have software system or internet access, administrators have an option to print and send claims by snail-mail.

Tools and Technologies

MS SQL 7.0/IIS 5.0/ASP/XML/COM.
Support of NSF format through separate COM component. Intelligent parser based on customizable instructions for parsing ASCI files into NSF format.

Benefits
The provided solution benefits both involved parties: medical institutions and insurance companies:
Reduced claim turnaround time due to the automated ICD and CDT codes validation.
Claims were available on-line to enable making quick correction.
A number of non-productive man-hours to review the patient's medical history were saved.


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