WO2002093286A2

WO2002093286A2 - Interactive network based insurance claim submission system and method

Info

Publication number: WO2002093286A2
Application number: PCT/CA2002/000700
Authority: WO
Inventors: Ilan Grosman; Lynn Bice; Cori Walker; Kevin Gan; Darren Willson-Rymer; Jane Goguen
Original assignee: Bce Emergis Inc.
Priority date: 2001-05-14
Filing date: 2002-05-13
Publication date: 2002-11-21
Also published as: CA2447244A1; WO2002093286A9; WO2002093286A3; CA2447244C; AU2002308330A1

Abstract

One aspect of the present invention provides an interactive digital claim submission system for providing multiple digital claim data files by a digital device to a network. The system comprises: a user interface for producing the data files from a predetermined claim data set, wherein the user interface provided by the digital device is connectable to the network. The system also uses a digital claim form set displayable on the user interface. The form set includes a number of data fields for receiving the data set and a claim type selector for selecting the data files to be completed and eventually submitted by a user. The user uses the user interface and the data set to complete the form set for each one of the selected data files. The data files can be forward by the submission system to an adjudication engine for the adjudication and processing of the various claim types.

Description

INTERACTIVE NETWORK BASED INSURANCE CLAIM SUBMISSION SYSTEM AND METHOD

The present invention relates to a network based insurance claim submission method and system for preparing and providing digital claim data files.

BACKGROUND OF THE INVENTION The preparation and processing of health care data transactions, such as insurance claims contributes to high administrative costs in the health insurance industry. Over the years, there have been many attempts to develop a faster and more cost effective claims preparation and processing system, since a large proportion of these claims have been and continue to be filed using paper claim formats. Current health care and other insurance related practices typically use some form of hard copy information to record the services that are provided to a patient, such as a medical drug prescription, on-site gathered details of property damage, prescription characteristics for eye wear, and various procedures performed for dental work. At the time the work is performed, the patient can provide payment to the provider of the services and then contact their respective insurance company or companies to submit an insurance claim(s). The providers can include pharmacies, hospitals, dentists, optometrists, and property repair services. One manual way of submitting insurance claim(s) is through regular mail services. In this case, the patient or member of the insurance company enters by hand printing or hand typing various personal data, and data contained on materials obtained from the provider, onto a paper based insurance form supplied by the insurance company. This claim information can include the patient's name, date of birth, data relating to the insurance company such as policy and group number, and details relating to the insured products and services obtained by the member. This information, as well as any other pertinent information, is used by the insurance company to help properly adjudicate the insurance claim. After the member completes the appropriate form or forms, they are mailed either to the insurance company, another carrier, or to a third party administrator to be processed. However, this manual system contains a number of disadvantages. One disadvantage is that upon receipt, a claims officer opens the mail envelope and manually re-keys the information on the enclosed paper based forms into their own computers. Additional manual labor may be needed to keep track of the total amount of claims submitted by each patient during a specified period and to keep track of other matters, such as for statistical purposes, thereby requiring an inefficient use of skilled labor to manually interpret and input or re-key data contained on the received paper claim forms. A further disadvantage is that paper forms usually contain errors that are often made when the forms are initially completed by the member. It can be easy to omit necessary information or to make mistakes when putting information onto the forms, or otherwise to have poor handwriting skills. Accordingly, if data is missing or is not correctly entered in the paper claim form, then the incomplete form must be returned by the claims officer to the member, which causes additional work and delays in the processing of the insurance claim. This increases the amount of resources used by the processor of the submitted claim form, as well as delay of payment to the member for the applicable insured services being sought. One further disadvantage is that the member may require assistance in filling out various data fields on the paper claim form. Therefore, the member may contact the insurance companies for further clarification when completing the form, thereby further adding to the cost of claim submission and processing. One additional disadvantage is the member usually has specific questions during the claim form preparation, on the type and extent of coverage provided by their insurance plan. Accordingly, the member typically obtains this feedback by contacting the insurance company directly, thereby using further company resources. Another well known system for claim submission to the insurance company or other administrators is through the use of an Electronic Data Interchange (referred to herein as EDI) to process transactions and insurance claims originating from the service providers, such as pharmacies and dental offices. EDI submission systems provide for electronic filing of claim forms from the provider of a particular service to the administrator who adj udicates the claim. The main advantage of this system is the elimination or reduction of the manual re-entry of insurance information by the claims officer into their computer systems, since an electronic copy of the claim is received. The other advantage is the timely response of the claim. The provider typically uses an approved software program to input the member data at the time the insured services are performed and then electronically submits that claim data in the form of an electronic insurance claim to the adjudication. However, this electronic claim submission system also has a number of disadvantages. The first disadvantage is that the claim submission is done on a claim by claim basis. Therefore in the case of multiple claims that are related in some way to one accident or a series of accidents or procedures, which involve use of multiple services such as dental, drug, vision, and/or property losses, individual claims for each claim type must be submitted separately by each of the corresponding providers. This disjointed submission process adds to the amount of insurance company resources required to process the various claims. It should be noted that in the case of vision and property losses et al., EDI systems are currently not available. Thereby requiring both electronic and manual filing of claim forms for different insured services related to a particular insured incident. This can also cause inefficiencies in claim reception, processing, and adjudication since multiple parallel processing systems must be employed for each claim. A further disadvantage is that the majority of providers must be able to interface with the majority of insurance company computer systems, which can have a variety of different operating systems and data formats. One solution is that the service provider can send an electronic claim to a third party vendor, who then performs a service such as screening of the form and then transmission to a particular members insurance company. However, there still remains the problem of individual submission of multiple independent claims for various service types, and the complication of coordinating allowable member benefits (COB) over the various different claim types and insurance companies. Furthermore, the vendor method of handling EDI claims can require separate organization of administrative material and multiple member mailings to the insured party for each individual adjudicated claim, thereby using additional company resources. In addition, screening of the forms by the vendor can still result in the omission of necessary data for adjudication, based on the complexity of the member situation. Furthermore, neither the EDI or vendor electronic claim submission systems provide feedback to the member as to the type and amount of coverage in regard to the claim data provided in the electronic claim submission. Therefore, once the member receives confirmation or settlement of their insurance claim, the member typically contacts the insurance company directly for clarification since the member does not have direct knowledge of the particular claim data used in the electronic claim submission. This lack of context by the member also contributes to a further drain on insurance company resources. It is an object of the present invention to provide an interactive claim submission system to obviate or mitigate some of presented disadvantages.

SUMMARY OF THE INVENTION One aspect of the present invention provides an interactive digital claim submission system for providing multiple digital claim data files by a digital device to a network. The system comprises: a user interface for producing the data files from a predetermined claim data set, wherein the user interface provided by the digital device is connectable to the network. The system also uses a digital claim form set displayable on the user interface. The form set includes a number of data fields for receiving the data set and a claim type selector for selecting the data files to be completed and eventually submitted by a user. The user uses the user interface and the data set to complete the form set for each one of the selected data files. The data files can be forward by the submission system to an adjudication engine for the adjudication and processing of the various claim types.

BRIEF DESCRIPTION OF THE DRAWINGS These and other features of the preferred embodiments of the invention will become more apparent in the following detailed description in which reference is made to the appended drawings wherein: Figure 1 is a schematic of a network based claim submission system; Figure 2 is a schematic of an electronic device of Figure 1; Figure 3 is a welcome screen displayable on the device of Figure 2; Figure 4 illustrates a screen to select network submission of an insurance claim; Figure 5 is a legal claims notice of screen of the system of Figure 1; Figure 6 shows a selection screen for different claim types of the system of Figure 1 ; Figure 7a illustrates an informational screen for dental form submission for the system of Figure 1; Figure 7b illustrates an informational screen for health form submission for the system of Figure 1 ; Figure 7c illustrates an informational screen for drug form submission for the system of Figure 1; Figure 7d illustrates an informational screen for health care spending information for the system of Figure 1 ; Figure 8 shows example DIN identifiers; Figure 9 is an example paper claim form for the system of Figure 1 ; Figure 10 is a welcome screen for a dental submission example using the system of Figure 1; Figure 11 illustrates a first screen containing data fields for the dental example of Figure 10; Figure 12 contains a second screen containing data fields for the dental example of Figure 10; Figure 13a contains a third screen containing data fields for the dental example of Figure 10; Figure 13b illustrates a help tool for the data fields of Figure 13a; Figure 13c shows corresponding error messages of the dental example of Figure 10; Figure 14 is an additional screen containing data fields for the dental example of Figure 10; Figure 15a shows co-ordination of benefits data fields for the system of Figure 1; Figure 15b illustrates a help box for the screen of Figure 15a; Figure 15c presents an information message to the screen of Figure 15a; Figure 16 presents a summary screen for the dental example of Figure 10; Figure 17 illustrates a submission screen for accrued electronic claim files; Figure 18 shows a welcome screen for a drug example; Figure 19 shows a first screen containing data fields for the drug example of Figure 18; Figure 20 illustrates a second screen containing additional data fields for the drug example of Figure 18; Figure 21a shows further data fields for the drug example of figure 18; Figure 21b shows confirmation data for the screen of Figure 21a; Figure 21c shows further help screens for the screen of Figure 21a; Figure 22 illustrates additional data fields for the drug example of Figure 18; Figure 23 shows further data fields for the drug example of Figure 18; Figure 24 presents a summary screen for the drug example of Figure 18; Figure 25 illustrates a submission screen for the drug example of Figure 18; Figure 26 is an operational flow chart for the claim submission system of Figure 1; and Figure 27 is an operational flow chart for data entry of the system of Figure 1. DESCRIPTION OF THE PREFERRED EMBODIMENTS Referring to Figure 1, a network 10 is presented for electronically assembling, filing, processing, and adjudication of insurance claims. Pre-determined claim data 12, typically in analogue paper format, can be entered in to digital systems, such as EDI provider systems 14, transaction clearing houses 16, and member accessible digital devices 18. The electronic or digitally based claim file 19, 19a is then sent via networks, such as the internet 20 to the adjudication centre 26. The entities 16 and 14 use the private VANS 22 or public WANS 24 send this electronic file 13 to the adjudication centre 26. Furthermore, the manual data 12 can be sent directly by a member 8 via telephone 28 data entry or by mail 30 to the adjudication centre 26, if desired. The adjudication centre 26 interacts with the clients or insurance companies 32 in response to the submitted file 19, 19a, to result in the generation of payment and an explanation of benefits (EOB) 34 which is then sent either to the banking services of the providers 14 or the member 8. A claim can be defined for dental as including one provider 14, for one member 8 with up to 7 services or procedure codes. For drug, one claim can be defined as one currency for one member 8 with up to 7 services or DINs, and for HCSA the one claim can be defined as for one family of the member 8 with up to 7 services included. In one embodiment of the present invention, preferably the customer or the member 8 can use the various electronic or digital devices 18, such as but not limited to cell phones, mobile computers, homes computers, pagers, and PDAs, to enter in and transmit the insurance data 12 over the network 20 to the adjudication centre 26 in an interactive fashion. It is recognized that the adjudication centre 26 can either be provided by a third party or directly by the insurance companies 32. In either case, the claim forms 48 can be presented to the member 8 as consistent with the look and feel of the customer access site of the insurance company 32. Referring to Figure 2, the generic device 18 can include an input device 38, such as a keyboard, microphone, and mouse, by which member insurance data 12 is entered into a memory unit 40. A processor 42 can co-ordinate through applicable software the entry of the data 12 into the memory 40 and then display the results on a screen or user interface 44. A storage medium 46 can also be connected to the device 18, wherein software instructions and/or personal data to assist in the entry of the insurance data 12 into a user interactive electronic or digitally based claim form 48, or series of forms, which is displayed on the screen 44. The form 48 can be presented in a member 8 selected language, such as English or French. Once completed, the claim data contained in the form set 48 can then be transmitted as the file 19, 19a to the network 20 and thereby to the adjudication centre 26. The adjudication centre 26 typically confirms receipt of the data file 19, 19a and can transmit an acknowledgment back to the device 18, preferably in substantially real time operation. The acknowledgment can take a number of forms, such as a simple acknowledgment of receipt or in more advanced systems as partial or complete adjudication results in response to the submitted claim insurance data 19, 19a. Transmission of the data 19 can be done by systems such as but not limited to wireless, modem, optic, and other available land-line transmission media, using applicable transmission methods and protocols. Access of the insurance forms 48 by the member 8 can be done through a web browser to connect to a respective web site or web portal contained on a network server, hosted by the adjudication centre 26 or the insurance companies 32. Data streams between the device 18 and the network 20 can be done using one or more known protocols such as but not limited to TCP/TCPIP standard protocols. Accordingly, the member 8 can launch the web browser to cause an HTML/DHTML/XML/JAVA window to appear on the screen 44 and thereby download or otherwise interact with the displayed forms 48 on the device 18. Referring to Figure 3, the member 8 can first access an insurance company 32 or administrator 26 home page, preferably at the convenience of the member 8, which asks for a particular ID 50 and Password 52 unique to the member 8. Figure 4 shows a further web page once the member 8 has logged on, which provides information on whether the member 8 wishes to print a claim form by activating field 54 and then mail it to the insurance company, or to select the choice for digital submission by link 56. Further information may be required, such as whether there are additional attachments to include 58 or whether the expenses total more than a pre-determined maximum by selection 60. Furthermore, a drop down box 62 provides selections for which country or jurisdiction the services were provided. These interactive features help to produce a preferably complete data file 19, 19a. Furthermore, any data for fraud prevention and audit purposes that is not submitted by the member 8 can be added to the file 19, 19a by the centre 26. Furthermore, for auditing purposes the adjudication centre 26 and/or insurance company 32 can contact the provider 14 to verify the services provided and detailed in the submitted forms 19, 19a. In addition, the system 10 can also have the ability to restrict access to members 8 that are suspected of committing fraud and abuse. Other auditing options include password updates by the member 8 when ever there is a change of spouse, or directions given to the member 8 by the forms 48 confirming present member address to inhibit the redirection of payment of benefits to persons other than the member 8. The protocol for a post processing review audit of the submitted claim 19, 19a can include review of the member's claim history, verification of submitted information with provider 14 by either phone or provider statement, and contacting the member 8 to request original receipts and paper submission as indicated. Certain criteria that can be used to flag submitted claims 19, 19a where auditing is required can include dollar value, abuseable codes, code and age discrepancies, and frequency of submissions and repeated submissions using the same claim data 12 for multiple data files 19, 19a. In addition, a relatively complete list of all providers 14 can be used to verify the credentials, designations, and accretions of the providers 14. These provider data bases can include unique identification numbers, facility names, address, phone numbers, that are updated and consistent. One additional warning process feature, is that when a provider 14 is profiled and the member 8 selects the Select All button 152, the member 8 is taken to a screen to answer questions for a pre-post payment audit. The questions for the audit can be linked to the services listed on the data field corresponding to the claim data filed 19, 19a. In this situation, in the claim files 19, 19a can be held until the member's 8 response to the additional screen is reviewed. Referring to Figure 5, when the member 8 selects for digital submission 56, a legal claim notice 64 can be presented on the screen 44 to inform the member 8 of the consequences for intentional falsification of insurance claim information, and to retain all receipts as proof of the electronic claim for a specified period of time. The retaining of receipts can assist in auditing of electronic claim submissions based on a random or pre- determined selection format. It should be noted that the legal notice 64 can also be included on the final screen of the submission process, before the claims data contained in the electronic forms 48 are transmitted over the network 20 as the file 19, 19a. Referring to Figure 6, a selection of different types of insurance claims, such as but not limited to dental 66, health 68, hearing 70, vision 72, property loss 74, and drug 75 may be selected by the member 8. Further information can be provided on the claim type selection page 81 by indicating whether the listed coverage is either active by statement 76 or inactive by statement 78. In the case of inactive or cancelled coverage, expenses could still be submitted within a grace period 80 or the page 81 could instruct the member 8 in an interactive fashion to contact the insurance company to re-activate the coverage by link 82. It should be noted that various insurance plans 84a and 84b can be displayed to the member 8, as well as a policy plan and member ID information 86, where the member 8 can be given directions as to how to change their current coverage. It should be noted that the information 86 can include other data specific to the customer account identified by the ID 50 and password 52, such as but not limited to the member's 8 address and other personal data including job, dependents, group member, and phone number. The member specific data 86 can be used to automatically populate appropriate data fields in subsequent insurance claim forms 48. In the case of member 8 entered data that can be subsequently considered as generic, this supplemental generic data could be periodically updated by the system 10 to the information 86 during the data entry process. The member 8 can also select the patient to be claimed, such as a spouse or dependent. Once the member 8 has interactively selected a particular claim type represented by links 66, 68, 70, 72, 74, and 75 under a particular insurance plan 84a, 84b, an informational screen 88a,b,c,d as shown in Figures 7a to 7d is presented to the member 8. The informational screens 88a,b,c,d correspond to the selection of a dental form, a health form, a drug form, or a spending account form respectively. It is noted that other forms relating to hearing, vision, and property loss can also be displayed. The information screen 88 lists the type of data 12 that the member 8 must have in order to properly fill out the series of claim forms 48. In particular, the information screen 88 has a series of interactive links 90 associated with the data that is required to fill out the corresponding data fields, should the member 8 have inquiries on the required information. Furthermore, during the data entry process, the member 8 can be informed of further required information. Referring to Figure 7c, a drug identification number (DIN) is identified by the claim drug form 88c. Upon activating the link 90 for the DIN, Figure 8 shows a DIN help file 92 that is presented to the member 8 on the screen 44 in order to help identify the proper information required, if it is absent or otherwise unreadable on the paper form 12. The information contained in the help file 92 could be searchable via the DIN number or other fields included using a traditional search engine. Referring to Figure 7a, a selection 94 can be used to interactively select either a claim for expenses or an estimate for services not yet performed. The member 8 may use the estimate feature to answer questions regarding plan features and coverage amounts. This estimation procedure can be used by the member 8 or provider 14 to determine before work is done as to what coverage can be expected based on the member's 8 particular circumstance. Other information, such as on Figure 7c asks whether expenses are over a pre-determined maximum amount 60 by selection 96 or whether co-ordination of benefits (COB) in regard to another insurance company is applicable for the present electronic insurance claim being submitted by selection 98. The system 10 can help determine and co-ordinate data entry and processing pertaining to first and second payer information.

DENTAL EXAMPLE Figure 9 shows a sample paper dental form 12a which contains: dental claim information 100, such as a unique number and the patient's office account number; provider service information 102, such as date of service, procedure code, tooth code, tooth surfaces, dentist fee, laboratory charge, and total charge; and member information 104, such as the group policy and division number, as well as the members name and any spousal insurance plans. Accordingly, when the member 8 wishes to submit a dental claim 19, 19a under a particular insurance plan 84, the member can select link 66 after logging into the insurance claim system 10, as explained above in relation to the above mentioned Figures 3 to 6. Therefore, the next screen 44 shown after selection of link 66 is the dental form screen 88a providing the member 8 with the information that will be required during the completion of the claim forms 48 related to dental work. This information is typically contained in paper data form 12a, which is provided to the member 8 by the provider(s) 14. Selection of the options 94 for submission of a claim for expenses or to provide an estimate for services not yet performed, and then selection of the next button 106 (see Figure 7a), results in the display of a preliminary information welcome screen 108 (see Figure 10) informing the member 8 of the general procedures to be followed during completion of the claim forms 48. Referring to Figure 11, Section 1 labeled by numeral 110 of the submission forms 48 contains the pre-populated insurance data 86 related to the specific ID 50 and Password 52. Furthermore, pre-supplied address information 112 of the member 8 can be pre-populated into the corresponding address fields, which are related to the ID 50 and Password 52 of the member 8. Member 8 is also given an opportunity to update this information, as required. Referring to Figure 12, Section 2 indicated by numeral 114 provides information about the dental provider 14. A drop box 116 can be used by the member 8 to access a plurality of pre-stored dentists names, addresses, and corresponding unique numbers 118, which can be used to pre-populate the dentist information fields 120 of the forms 48. The member 8 can also manually enter in such data if not contained in the box 116 list. Furthermore, data can be provided by the member 8, as to whether the provider 14 should be paid directly instead of the member 8 by using selections 121 and 122. Referring to Figure 13a, Section 3 provides data fields 124 which correspond to the provider 14 service information 102 contained in form 12a (see Figure 9). Also present on the Section 3 form are various help icons 126 which can be used for interactively accessing a pop-up help screen 128 (see Figure 13b) to provide help in filing out those particular corresponding data fields during the completion of the claim forms 48. It should be noted that the pre-determined maximum limit 60, in this case $1,000.00, can be used to help limit the liability of the claim form submission process, to be assumed by the insurance company upon pay out of the submitted claim file 19, 19a. This maximum limit 60 can be set according to a general rule or tailored to the specific needs or situations of selected members 8. Any attempt by the member 8 to submit a claim over the limit 60 can result in termination of the digital submission process and the member 8 will be directed to submit a paper claim 30. Also contained on the Section 3 form are fields 128 and 130, which correspond to whether the present insurance claim may be coverable under multiple insurance company plans. Figure 13c displays error codes 125 that are presented to the member 8 as the system 10 interactively checks the data 12 entered in to the forms 48. The member 8 is then given the opportunity to correct the error(s), thereby accomplishing a level one edit to help ensure that the completed forms 48 are free of obvious errors and contain all required data for the adjudication process. The error checking can help to reduce the frequency of mail back forms to the member 8 by the adjudicator 26. Figure 14 also contains further information to be provided in the claim submission forms 48, concerning dental work particulars and whether it is a repeat procedure. Figures 15a and 15b can be used to provide claim data to facilitate the co-ordination of benefits between spousal or other related insurance plans. Links 90 can be used to assist the member 8 in determining whether the various data fields 134 are applicable to a particular situation, as explained by the pop-up window 128 shown in Figure 15b. In particular, travel insurance plans and student insurance plans are listed since they are typically the first payer in regard to insurance claims. Upon selection of choice 91 , the member can be notified by a message 127 (see Figure 15c) indicating that by selecting 91 the present insurance claim may not be applicable. The information contained in data fields 134 can facilitate in using insurance plan sharing to provide for the digital submission and eventual adjudication of overlapping insurance coverages. Figure 16 shows a summary page 136 asking the member 8 to check whether the information that has been entered is correct and to make any further changes that are necessary, by selecting the change button 140. Selection of this button 140 will direct the member 8 to the appropriate data field in order to allow modification thereof. The member 8 is also presented with a print page option 142 in order to keep a copy of the completed claim forms 48 for the member's 8 records. Once the member 8 is satisfied that the information entered is correct, selection of the submission button 144 produces the claim file 19, 19a for transmission to the adjudication centre 26 via the network 20. A further confirmation page 146 confirms that the data file 19, 19a has been created for the completed dental insurance claim and then gives the member 8 an interactive option to enter in data for another dental claim using selection 148. In the case of selecting another dental claim by the selection 148, the member 8 can bypass certain forms 48 that contain only generic information which will be automatically pre-populated into their corresponding data fields for the new claim submission, which is known as the "maintain state" for the form 48 completion process. Accordingly, Section 1, identified by 110, and Section 2, identified by 114, may be skipped by the member 8 since these sections will be pre-populated by the generic information already entered through the completion of the first dental claim, as described in the above dental example, so that the member 8 is then immediately brought by selection 148 to the Section 3 screen 44 containing the dental work information data fields 124. Therefore, the process of submitting multiple insurance claims of the same type can be streamlined through using generic or maintain state data to pre-populate respective data fields in the subsequent claim forms 48 corresponding to the additional insurance claim file 19, 19a. If the member 8 uses the insurance form 146 to select link 150 to submit a different kind of claim type, the member 8 is subsequently shown the various claim type selections 66, 68, 70, 72, 74, and 75 as given in the page 81 of Figure 6. The member 8 then selects and follows the instructions for completing the second different claim, as detailed below with reference to a drug claim by way of example only, and then is led again to the confirmation page 146 indicating whether the further insurance claim file 19, 19a is to be submitted. Once the member 8 has finished entering all applicable data for various insurance claims and the corresponding data files 19, 19a for each respective claim have been created, the member 8 can select the Submit All button 152, thereby transmitting as a package all of the individual insurance claims 19, 19a over the network 20 to the adjudication centre 26. It should be noted that applicable generic data 86 from the first claim file 19, 19a could also be used to pre-populate related data fields during completion of the record or subsequent data files.

DRUG CLAIM EXAMPLE Upon selection of link 150 after completion of the above detailed dental claim and preferably before the selection of the submittal button 152, the member 8 has the opportunity to be directed to a list of various claim types indicated on the claim type selection screen 81 of Figure 6. As an example, the member 8 has selected link 75 indicating the desire to prepare the drug claim submission file 19a, in addition to the previously prepared dental forms 19,. After selection of the link 75, the member 8 is brought to form 88c detailing particular data required in the paper form 12 that will be needed to complete the drug claim file 19a. Once form 88c is reviewed, the member 8 is brought to the welcome screen 108a, shown in Figure 18, which is similar to the screen 108 of Figure 10. The next form shown to the member 8 is drug Section 1 identified by 110a in Figure 19. It should be noted that generic data 86, the phone number, and address information 112 is identical to that contained in the dental information in form 110 shown in Figure 11, since the generic information has been kept in the maintain state and thereby pre-populated into the corresponding data fields of the second claim file 19a corresponding to the drug claim selection 75. This pre- population procedure helps to streamline the digital claim submission process using the system 10. Referring to Figure 20, drug Section 2 contains more information that is required to be filed out from the data 12 and provides the member 8 with interactive tips 156 on maximum amounts 60, use of links 90, and identification marks 158 to denote additional information screens 128 and required fields respectively. In particular, selection of the "Yes" option of choice 159 can result in the adaptive inclusion of indication 161 (see Figure 21a) corresponding to a required DIN. Data field 160 of Figure 21a requires the entry of the DIN number recorded on the drug data form 12. The DIN number is a unique identifier for each drug, drug form, and application size, as shown in list 92 in Figure 8. Accordingly, entry of the DIN number in field 160 can automatically pre-populate related fields 162, 164, and 166 in Figure 21b. Furthermore, Figure 21b also shows the result of selection of help button 168 by the member 8, which provides the pop-up help screen 128 which gives a definition of the prescription of the RX number. Additionally, once the DIN number is entered in field 160, the corresponding full name 169 of the drug appears on the screen 44, to act as an interactive check for the member 8 to confirm whether the DIN number entered in field 160 is correct. Furthermore, link 170 gives the member 8 the option of submitting a paper health claim form 30 if the drug information shown by field 168 does not correspond with the DIN number entered in field 160, upon inspection of the corresponding information contained in the paper form 12. Figure 21c provides another example of the pop-up help text 128. The automatic or interactive features of the forms 48 help to dynamically update the data 12 required, based on the member's 8 claim situation. Figures 22 and 23 contain further information to be entered in the claim forms 48 from the data 12. In particular, the pharmacy that dispensed the drug is entered in field 172, which could be provided as a drop down box, which upon selection of an appropriate pharmacy could pre-populate the corresponding address and phone number fields 174 of the pharmacy. Due to the detailed nature of the information required for a particular drug, the member 8 could be supplied with a further interactive option 176 to add another series of drug claim forms 48 to be included in the same drug claim file 19a, thereby providing multiple claim files 19, 19a from a single member 8 claim submission session using the form 48. Referring to Figure 24 a confirmation page is presented, similar to that for the above discussed dental claim to confirm the claim information 136 (see Figure 16). The member 8 is again asked whether changes are required which can be accomplished through selection of change button 140 and a copy of the drug claim can be printed for the member's 8 files by selection of the print page button 142. Clicking of the Submit All button 144 will result in creating the drug claim file 19a containing one or more drugs as filled in by the member 8. Accordingly, once the drug claim file 19a is created, the member 8 is presented with the confirmation screen 146a that the file 19a has been created and is given the choice to select another drug claim using link 149, or submit another kind of claim using link 150. If the member 8 is finished with all claims to be submitted, then selection of the Submit All button 152 will result in the transmission of all claim data files 19, 19a created over the network 20 to the adjudication centre 26. Simultaneous submission of and/or processing of files 19, 19a containing multiple insurance claims, either containing the same or different claim types, can help streamline the adjudication process, as well as the insurance companies back end systems of issuing EOBs and payment concerning the multiple claims. In particular, a single or reduced number of EOBs and payment portions could be the result of the integrated adjudication process based on the multiply received claim data contained in the files 19, 19a, as compared to traditional separate EOBs and payments for each individual insurance claim submitted. The present system 10 helps to co-ordinate the receiving and processing of related claim files 19, 19a through interactive selection of various claim types and related claim submission forms 48, which by way of example only are directed to the member 8 through claim forms 81 and 146 for providing an opportunity to submit multiple insurance claims. Generally, the above described claim form submission system 10 provides the member 8 with the ability to interactively create electronic and/or digital data files 19, 19a, using information contained in the data 12 provided by the provider 14 to the member 8. The system 10 allows the member 8 to create multiple claim data files 19, 19a for different claim types, such as but not limited to HCSA, dental 66, health 68, hearing 70, vision 72, property loss 74, and drug 75. Preferably the forms 48 for the different claim types contain substantially the same data fields and information, except for fields and information specific to the selected claim type. The claim type selection and data entry process is repeated for the various claim types by the member 8 to create various corresponding data files 19, 19a, prior to submission of all the claim data contained therein to the adjudication centre 26. Generic or member specific data 86 can be used in the "maintain state" for pre-population of generic or reused data fields, thereby streamlining the data entry process. This can include same claim form 48, same member 8, same or different provider 14, and/or different patient. During completion of the claim forms 48, the member 8 can access various help features to assist in the completion of the forms 48, and automatic error checking is employed by the system 10 to perform a first level edit to produce cohesive digital data files 19, 19a wherein the contained claim data co-relates to one another and is preferably free of typographical errors. This automatic error checking process helps to eliminate the sending back of an incomplete claim form 30 to the member 8 by the adjudication centre 26. Additionally, the system 10 can interactively update the context of forms 48, based on data 12 entered by the member 8. Furthermore, the system 10 also provides feedback to the member 8 during the completion of the forms 48, on questions such as but not limited to types of insurance plans, coverage amounts, and whether the forms 48 are complete. Submission of various different claim files 19, 19a as one combined data file to the adjudication centre 26 facilitates the generation of a single EOB and can streamline the payment process upon approval of the submitted insurance claims. The EOB and/or payment can be relayed to the member 8 in substantially real time or by a partial judgement or an acknowledgement of receipt can be given pending further processing. The system 10 also has the ability to monitor the claim submission process, so as to hinder the submission of the same file 19, 19a more than once, to limit duplication of claim submission. This duplication monitoring can be done at the time of data entry during the user session of the member 8 with the forms 48, or in receipt of the submitted files 19, 19a by the adjudication centre 26 as a feedback process to inform the member 8 that the particular claim desired has already been submitted. In operation of the system 10, referring to Figure 26, the member 8 first obtains the claim data 12 from the various applicable providers 14 at step 180. The member 8 then accesses the network claim submission system 10 using the device 18 and proceeds to follow the instructions at step 182, as displayed on the screen 44. Standard and/or current "time out" protocols on member access to the form 48 are used to manage network access. The member 8 determines through the claim forms 48 whether the current claim situation is applicable at step 184. If the claim situation is not applicable, then the member 8 prints the available forms 48 and completes them manually at step 186. If the desired claim is applicable, then the member selects the claim type from form 81 at step 188 and then proceeds to enter the claim data 12 to produce the network file 19, 19a at step 190. Once the insurance claim is completed, the member 8 has the choice to submit another claim through form 146 at step 192. If applicable, then the member 8 repeats steps 184, 186, 188, 190, and 192 until all applicable claim types or claims of the same type are completed in either the paper or digital form. The member then transmits the files 19, 19a, and 30 if applicable, to the adjudication centre 26 at step 194. The adjudication centre then either processes the corresponding insurance claims or sends them on to the respective insurance company 32 for processing at step 196. A decision to audit the submitted insurance claims can be done at step 198, either before the issuance of the EOB and payment as shown, or afterwards if desired. In the case where the audit is conducted, the member 8 is contacted at step 200 and the decision is made whether the claim data contained in the files 19, 19a is correct at step 202, either resulting in an issue of the EOB payment at step 204 or termination of the insurance claim adjudication process. If an audit is not decided upon, then the EOB and payment are issued at step 204 either by the adjudication centre 26 or the respective insurance companies 32 and the adjudication process is completed. Referring to Figure 27, the data entry step 190 of Figure 26 is explained in greater detail. In particular, the member 8 after completing step 184 proceeds to enter the claim data at step 206. During the completion of the forms 48, the member 8 may have an inquiry at step 208 as to what a specific term means or clarification on either their insurance plan or the data to be entered, for example. Accordingly, upon selection of the help links 90 and help icons 126, the member 8 can be presented with a corresponding help screen 128 at step 210. The member then continues on to enter the claim data at step 206. If a data entry error is encountered by the system 10 at step 212, the required correction information to the displayed member 8 at step 214 (see Figure 13c) and then the member 8 proceeds to enter the correct claim data at step 206. If no data error is present, then the claim data entry continues. If some of the data entered effects the information to be displayed by the forms 48 to the member 8, such as described with reference to the drug example with indicator 158 and error check message 168, as detected at step 216, the content of the forms 48 is updated at step 218 and then the member 8 can continue on with data entry at step 206. At certain stages during the data entry process, the member 8 may have additional improper data, which negates the ability to continue on in the digital claim submission process, which is decided at step 220. Accordingly, the member 8 is presented with a message to either print the required forms and complete manually and/or to terminate the claims submission process in absence of the required data at step 222. It should be noted that the member 8 is given the ability at multiple times during the data entry process to exit the forms 48 without submitting a digital claim 19, 19a. Once the data entry is complete, as decided at step 224 with reference to the summary page 136 (see Figure 16), the member 8 may make changes by selecting button 140, print a copy of the completed forms 48 by selection of button 142, or select the submission button 144 to either proceed to enter further data at step 206 or proceed to step 192. It is recognized that the data 12 can also be provided to the member 8 in an intermediate electronic or digital form, which is then used to complete the claim submission forms 48. This intermediate data can include X-rays and other picture data, which can be attached to the claim data files 19, 19a for transmission to the centre 26. Furthermore, it is also recognized that as each claim file 19, 19a is completed by the member 8, the individual data files 19, 19a can be sent separately to the adjudication centre 26. Upon completion and sending of all individual claim files 19, 19a to the centre 26, the member 8 could use the Submit All button 152 to signal completion of the form submission process. The centre 26 could then assemble all claim files 19, 19a for adjudication and submit a single or reduced number of corresponding EOB and payments accordingly. It is also recognized that the provider 14 or other third parties could use the system 10 and form 48 to submit multiple claims 19, 19a. Furthermore, it is recognized that on-line help or tutorials with sample pharmacy receipts and legend, as well as sample claim forms 48 for each benefit stream can be provided to the member 8 so as to assist in the completion of the required data entry fields to produce the file 19, 19a. Although the invention has been described with reference o certain specific embodiments, various modifications thereof will be apparent to those skilled in the art without departing from the spirit and scope of the invention as outlined in the claims appended hereto.

Claims

THE EMBODIMENTS OF THE INVENTION IN WHICH AN EXCLUSIVE PROPERTY OR PRIVILEGE IS CLAIMED ARE DEFINED AS FOLLOWS:

1. An interactive digital claim submission system for providing multiple digital claim data files by a digital device to a network, the system comprising: a) a user interface for generating the data files from a predetermined claim data set, the user interface provided by the digital device connectable to said network; b) a digital claim form set displayable on said user interface, the form set including a number of data fields for receiving the data set; and c) a claim type selector to select the data files for submission to said network; wherein said user interface monitors the entry of said data set to complete said form set for each one of the selected data files.

2. The submission system according to claim 1, wherein said claim type selector includes a selection menu continuing a plurality of different claim types for selection by a user of said user interface.

3. The submission system according to claim 2, wherein the claim types are selected from the group comprising HCSA, health, dental, hearing, vision, property loss, and drug.

4. The submission system according to claim 2 further including an information form having a list of data required to complete the claim form set, the content of the list related to the claim type selected.

5. The submission system according to claim 4 further comprising an interactive link located on said information form for providing completion assistance to the user.

6. The submission system according to claim 2 further comprising a prepopulation function for prepopulating corresponding ones or the data fields with information from the predetermined claim data set, the information provided by the user for the form set of a previously selected claim type.

7. The submission system according to claim 6, wherein the prepopulation information includes identification information of the user.

8. The submission system according to claim 7, wherein the prepopulation information is selected from the group comprising group policy, division number, user name, spousal insurance plan number, user contact information, and dependent information.

9. The submission system according to claim 7, wherein the identification information is dynamically selected by the prepopulation function from a system database, the selection according to a unique identifier provided by the user.

10. The submission system according to claim 6 further comprising a service provider database for providing provider information to said prepopulation function.

11. The submission system according to claim 6 further comprising a product database for providing product information to said prepopulation function.

12. The submission system according to claim 2 further comprising an interactive feedback function for providing the user with supplemental information to assist in completion of corresponding data fields of the claim form set.

13. The submission system according to claim 12, wherein the feedback function provides an error indicator to said user interface for identifying incorrect or omitted data by said user related to the data fields of the claim form set.

14. The submission system according to claim 12, wherein the feedback function provides benefits or plan information applicable to the user.

15. The submission system according to claim 2, further comprising a submission function for coordinating the submission of a plurality of the data files to said network.

16. The submission system according to claim 15, wherein said submission function provides a submission selector to create the data file corresponding to the completed claim form set of the selected claim type.

17. The submission system according to claim 16, wherein the submission selector is provided for each claim type chosen by said user to create the corresponding set of multiple digital claim data files.

18. The submission system according to claim 17, wherein said submission function further comprises a file summary provided to the user by said user interface prior to submission of the set of multiple digital claim data files to said network.

19. The submission system according to claim 17, wherein the set is submitted as a series of separate data files.

20. The submission system according to claim 17, wherein the set is submitted as a combined data file.

21. The submission system according to claim 17, wherein the data files are related to a same insured incident involving different claim types.

22. The submission system according to claim 17, wherein the data files are related to a same insured incident involving the same claim types.

23. The submission system according to claim 17, wherein the data files are related to different insured incidents involving different claim types.

24. The submission system according to claim 17, wherein the data files are related to different insured incidents involving the same claim types.

25. The submission system according to claim 2 further comprising an adaptive function for customizing the presentation of the data fields to the user interface in relation to previously supplied claim information of the claim data set.

26. The submission system according to claim 25, wherein the content of the digital claim form set is modified by the adaptive function.

27. The submission system according to claim 2, wherein the digital device is selected from the group comprising a cell phone, personal computer, and PDA.

28. The submission system according to claim 2, wherein the predetermined claim data set includes electronic pictorial data.

29. An interactive method for providing multiple digital claim data files to a network for adjudication, the method comprising the steps of: a) selecting each claim type from a plurality of different claim types; b) presenting a digital claim form set including a number of data fields related to each claim type selection through a user interface; c) providing a predetermined claim data set to be received by the data fields for generating the data file corresponding to each of the claim types selected; and d) coordinating the selection of each of the generated files for submission to said network; wherein the entry of the predetermined claim data set is monitored for completing the claim form set for each one of the selected claim types.

30. The interactive method according to claim 29 further comprising the step of providing a selection menu having the plurality of different claim types through the user interface.

31. The interactive method according to claim 29 further comprising the step of providing an information form having a list of data required to complete the claim form set, the content of the list related to the claim type selected.

32. The interactive method according to claim 31 further comprising the step of interactively linking completion assistance information for the form set through the information form.

33. The interactive method according to claim 29 further comprising the step of prepopulating corresponding ones of the data fields with information from the predetermined claim data set provided by the user for the form set of a previously selected claim type.

34. The interactive method according to claim 33, wherein the prepopulation information includes identification information related to the user.

35. The interactive method according to claim 34, wherein the prepopulation information is selected from the group comprising group policy, division number, user name, spousal insurance plan number, user contact information, and dependent information.

36. The interactive method according to claim 34, wherein the identification information is dynamically selected by the prepopulation function from a system database, the selection according to a unique identifier provided by the user.

37. The interactive method according to claim 33 further comprising the step of providing provider information from a service provider database for the prepopulation of the data fields.

38. The interactive method according to claim 33 further comprising the step of providing product information from a product database for the prepopulation of the data fields.

39. The interactive method according to claim 30 further comprising the step of assisting the completion of the data fields by providing corresponding supplemental information to the user in an interactive manner.

40. The interactive method according to claim 39, wherein the supplemental information includes an error indicator for identifying incorrect or emitted data by said user related to the data fields of the claim form set.

41. The interactive method according to claim 39, wherein the supplemental information includes benefits or plan information applicable to the user.

42. The interactive method according to claim 39, wherein the supplemental information includes estimate information for providing cost estimates of insurable incidents.

43. The interactive method according to claim 30 further comprising the step of coordinating the submission of a plurality of the data files to said network in a predetermined manner.

44. The interactive method according to claim 43 further comprising the step of creating the data files corresponding to the completed claim form set of the selected claim type in response to a submission selection option.

45. The interactive method according to claim 44, wherein the submission selection is provided for each claim type chosen by said user to create the corresponding set of multiple digital claim data files.

46. The interactive method according to claim 45 further comprising the step of providing a file summary to the user prior to the submission selection of the set of multiple digital claim data files to said network.

47. The interactive method according to claim 45, wherein the set is submitted as a series of separate data files.

48. The interactive method according to claim 45, wherein the set is submitted as a combined data file.

49. The interactive method according to claim 45, wherein the data files are related to a same insured incident involving different claim types.

50. The interactive method according to claim 45, wherein the data files are related to a same insured incident involving the same claim types.

51. The interactive method according to claim 45, wherein the data files are related to different insured incidents involving different claim types.

52. The interactive method according to claim 45, wherein the data files are related to different insured incidents involving the same claim types.

53. The interactive method according to claim 30 further comprising the step of customizing the presentation of the data fields to the user in an adaptive manner in response to previously supplied claim information of the claim data set.

54. The interactive method according to claim 53, wherein the content of the digital claim form set is modified adaptively and subsequently presented to the ever interface in the modified format.

55. The interactive method according to claim 30, wherein the predetermined claim data set comprises electronic pictorial data.

56. The interactive method according to claim 30 further comprising the step of presenting a legal claim notice to the user notifying of the consequences of intentional falsification of the claim data set entered in the data fields.

57. The interactive method according to claim 56, wherein acknowledgement of the legal claim notice is required prior to generating the data files corresponding to each of the claim types selected.

58. The interactive method according to claim 39, wherein the supplemental information provides a maximum claim amount permitted by the adjudication of the digital claim data files.

59. The interactive method according to claim 58 further comprising the step of directing the user to complete a paper claim form in response to claim amounts exceeding the maximum claim amount.

60. A computer program product for submitting multiple digital claim data files by a digital device to a network, the product comprising: a) a computer readable medium; b) a user interface module stored on the computer readable medium for coordinating the generation of the data files from a predetermined claim data set, the user interface module operable by the digital device connectable to said network; c) a digital claim form module coupled to said user interface module for presenting a digital claim form set by said user interface module, the form set including a number of data fields for receiving the data set; and d) a claim type selector module for selecting the data files to coordinate the submission of said data files to said network; wherein said user interface module monitors the entry of said data set in an interactive manner for completing the form set for each one of the selected data files.