JPH05509424A - Real-time utility for insurance administration and medical information - Google Patents

Abstract

(57) [Summary] This bulletin contains application data before electronic filing, so abstract data is not recorded.

Description

[Detailed description of the invention] Real-time utility for insurance administrative management and medical information Senonmi 1ζ0 SenryoQ Saved by This application was filed on June 30, 1987 and is currently filed under U.S. Patent No. 1, No. 4.916. , 611, which is a partial continuation of patent application serial number 068,240. Shokajo■Hashisato Mitsuno The present invention processes insurance claims and is particularly useful for medical practitioners, medical intermediaries and others. Real-time to provide online information for use by medical information users Concerning computerized systems.

Conventional technique ball A form of medical insurance claims processing system was submitted to Mr. Pritchard on January 1, 1985. No. 4,49L725. This patent is a book Cited as a reference in the specification. This patent allows patients seeking medical treatment to A system for presenting a D (identification) card is disclosed. The coded data It is electronically read from the card and transferred to a central intermediary computer. Intermediary con The computer checks the database to see if the patient is covered by insurance. 1. If applicable, whether insurance will fully cover the patient's medical care. Check. The intermediary computer immediately informs the doctor of the retrieved information. .

Mr. Pritchard's patent does not answer the following questions: (1) How to derive the information contained in the database 6 (2) How is the data derived? Ui, when will it be updated? (3) How is medical data handled and updated? Is it kept in ta? (4) How to improve medical care through real-time judgment by qualified personnel Will it save the administrative sponsor money? (5) To provide emergency treatment to patients. How can healthcare professionals use the information in the database? (6) Various medical treatments Minimize financial losses for healthcare providers, healthcare professionals and insurance plan sponsors The utility of medical information is enhanced by providing the necessary heating information for patients. Is it possible to reduce medical costs? (7) Data generated in changing daily life The control you need to make all your financial and medical decisions by leveraging the How does a closed-loop real-time system provide this mechanism?

The question of how and when databases can be updated is important for employees. Increased costs for employers offering group health insurance plans (0 cases impacting For example, the database contains a list of insured employees; Must be renewed if the employee leaves the company, but there are various delays Due to this, the list may only be updated once a month. moon like this Employees who have left the company, whether intentionally or not, can be renewed once every year. will not be able to receive treatment under medical insurance until his name is removed from the register. The result is that it retains its status. -Assuming that each month is 30 days, On average, all employed employees receive insurance coverage at the employer's expense for 15 days after leaving the company. will remain applicable.

Additionally, there may be other sources of cost burden for employers due to retired employees.

Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (P, L, 99 272), under certain conditions, an employer may continue to cover the employee's insurance even after the employment has ended. If a former employee who is stipulated that he or she must continue to receive medical treatment, his or her name shall be Both because the books are updated later and because of the C0BRA law, employees This complicates the issue because it becomes unclear whether the user is covered by insurance. Minimize the risk of non-payment In order to ensure that the employee is eligible for insurance benefits, the treating physician It is extremely important that the teacher knows.

Other workers in the medical field are also trying to minimize various risks to reduce their financial burden. have a similar opportunity to. The cost of malpractice insurance for a given healthcare professional based on information provided to medical malpractice insurance payers through information utilities. The nature of physicians' medical care regarding high-risk procedures could be reduced by medical malpractice insurance payers, and other available information. At the other end of the spectrum, online Real-time information allows the relevant doctor to decide on the appropriate treatment for an unconscious patient. This scenario can be useful in situations where the patient can provide useful information to the doctor. Medical Malpractice Insurance To payers, this doctor has a risk of medical malpractice that would lead to a reduction in insurance premiums. This serves to inform that technology has been adopted to minimize risks.

The present invention is a computer system for administrative management of medical insurance claims. By using real-time processing technology, medical It provides an online medical information utility.

Outline of Ω In one form of the invention, a third party office administrator can maintain a real-time database. The database contains information under a given insurance plan. Comprehensive list of all people eligible for insurance coverage and covered by insurance The types of benefits applicable, including specific medical treatments, and the amount of benefits for each procedure. included. The database also contains medical records and medical data for each member of the group. Files are also included. Physicians or other medical personnel involved in medical care must Whether the person is included in the list of insured persons covered by the insurance for the specified insurance plan. To check whether the treatment you are undergoing is covered by insurance and the amount of benefits. The office has communication equipment that can communicate with the office management computer in real time.

When the database shows that your insurance actually covers the proposed medical care, , doctors can request benefits to be paid immediately, for example by bank transfer. can.

Medical service workers' terminals are equipped with a period card reader, keyboard, and digital display. Each meeting of the insurance coverage group preferably includes a spray screen. Each member is given a time card on which certain information about the member is encoded. card is swiped through a card reader. By accessing a central database , the healthcare professional will be asked if this group member is covered by the group insurance plan. , the range of validity and other data can be determined.

Sponsoring an insurance plan, such as an employer that provides insurance coverage for the patients of its employees. The server also has communication equipment, and this equipment can communicate with the office management complex. , in a different way than that of a doctor. This means that employers can access data in real time. Base can be modified. For example, an employer may have an i position at the company, or Add or delete people who have been covered by the insurance from the list of members covered by the insurance.

In addition, an employer may change the benefit amount for treating a patient with a sprained wrist from $X to $Y. I can do it.

In addition, employers may conduct audits of insurance plan activities based on database reports. For example, by addressing the database, an employer can In another aspect of the invention, the claims activity of each insured can be tracked. The database may further include medical data files for each group member. .

This file can be accessed by medical personnel. to medical workers Therefore, all treatments or services performed are entered through the medical worker's terminal, The member's medical data file is updated. Medical data files are constantly updated. It also provides information on the patient's changing medical conditions, which can be used to request information. can be accessed by healthcare professionals. In this way, the treating physician Physicians may use medical data files as an adjunct to the records maintained in their practice. I can do it.

The system also provides direct payments for medical services provided by healthcare professionals. It is also possible to include a transfer device that can receive the information. This is the central controller A form of direct connection between computers and financial institutions such as banks, credit card companies, etc. can be taken. Medical professionals evaluate each member's insurance coverage and take appropriate measures. After the procedure is performed, the amount authorized by the insurance plan for that particular procedure is It can be wired to the person in question, or transmission by check is also possible. the system Since it is also linked to external financial periods, if there are deductions or patient-paid payments, Healthcare workers can be electronically sent a breakdown of the payment amount on the same day the procedure is performed. Ru. In this way, the system eliminates the need for efforts to collect money after the fact.

In a family with two earners, an individual may be enrolled in two or more insurance plans. Since it is common for group members to have multiple Include records that allow identification and ranking of coverage provided by plans. I can do it. In this way, health service workers can What part of the benefits for the treatment the patient receives is determined by each insurance plan. Will you be paid? can be approved. Furthermore, by using this record Therefore, the central processing unit recognizes funds from multiple insurance bracas, makes transfers, and Medical benefits can be automatically coordinated.

This utility can also be used in conjunction with an information subscriber terminal.

These information subscriber terminals allow users to certify themselves as eligible for insurance plans, Level of benefits, member's medical level and medical data, etc., and statistics of insurance plan members a central database for various data stored in the terminal, such as can call the source. In this way, group members can assess their own qualifications. You can check whether there are any You can check whether you will receive insurance plan benefits. The research company I learned how many members of the insurance plan received treatment for coronary artery disease, for example. There are cases where Medical malpractice insurance companies provide specific medical malpractice insurance claims to certain doctors. Therefore, you may want to know how many high-risk medical procedures have been performed.

The system has a paging function, so medical personnel such as first aid award personnel can Patient who can quickly call the system in card reading mode to receive emergency treatment find out if a patient has an allergy to a drug, for example, or find out a patient's blood type. It is possible to confirm. For this purpose, the central processing unit be programmed to allow card reader operation. After the member has been identified, Emergency Treatment Award staff will screen unnecessary data. You can quickly call up important information without needing it.

In summary, the utilities disclosed herein may be used to assist a patient in undergoing a medical procedure. Healthcare professionals can instantly access covered benefit levels, along with eligibility. , which provides an online, interactive, real-time system. Furthermore, Insurance benefit sponsors can also update group membership status online. , there is no “lag time” between changing benefit status and entering it into the system. It becomes. Medical professionals can always be sure of knowing the exact eligibility status of each member.

Drawings FIG. 1 is a simplified schematic diagram of the system.

FIG. 2 is a block diagram of the main components of the system.

3 to 34 are flowcharts showing the operation of each of the buttons in FIG. 2.

Light Tsui M Pressure Kasa Theory 2 FIG. 1 is a simplified schematic diagram of one embodiment of the invention. Office management computer 3 maintains a database 6 of each insurance plan offered by the employer 2.

File 7 is the Plan ABC database maintained by Employer 2, Company α. It shows the base. File 7 includes all insured employees of α company and their spouses. and a list of dependents. In addition, files may not be covered by insurance. Contains a list of all medical procedures. (Each treatment is generally a treatment procedure. The reason for this is that after diagnosing the symptoms, doctors treat specific monochromatic people. There are several different methods available, depending on the circumstances and/or characteristics of the particular diagnosis. This is because one decision can determine the treatment method. For example, patient The diagnosis of Mr. Dames' wrist sprain and subsequent diagnosis is appropriate in the circumstances. There are therapeutic procedures, or treatments, that can be considered. ) File 7 further describes each medical procedure. It also includes a list of the amounts to be paid0.For example, file 7 contains a list of amounts to be paid. $X is entered for treatment I, which means insurance plan ABC will cover the wrist sprain treatment. This means paying $X. In addition, Mr. Adams If you are also enrolled in multiple plans, that information will also be used as the rank of benefits under each plan. Coordination of insurance benefits as included in his file records along with and scope. It is possible to

In addition to insurance-related information about Mr. Adams, the database includes complete medical records. Contains cents. If Mr. Adams is being treated by another doctor for another condition, If so, please tell us who the treating doctor was, the type of bacterial treatment and if Mr. Adams was present. Patient records display current medications. accessing such information; helps physicians make better informed treatment and medication decisions. Can be done. This further reduces the time required to interview patients directly, Reduced risk of patients forgetting or becoming confused about the nature of the procedure and/or medication It disappears.

When Patient 9 visits the doctor for a sprained wrist, the patient is enrolled in insurance plan ABC. Present your ID card 15 as proof of your identity. The doctor uses the data terminal 18 is used to communicate with the office management computer 3 over the data link 21, and the computer Diagnose the patient's name (Adams) and the patient's insurance plan (ABC in this case). Enter along with the result (wrist sprain). Computer 3 is a device that supports Plan ABC. Specify the location of database record 7 and check whether the patient is on the insured list. Plan ABC will pay the doctor for the given diagnosis (wrist sprain). We will confirm whether or not and present the benefit amount. If Plan XYZ also applies, The amount paid by run XYZ is also presented. The patient's medical record is on the terminal 18 can be viewed on a screen or in hard copy (hard copy is not printed). This is a term used in this field to indicate output in a format. ) is printed by the printer 131 of the terminal. The physician may be responsible for the diagnosis, treatment and administration (and) or prescribed medication. Medical records can be updated. Finally, physicians can check validity in real time. Submit the adjudicated claim form electronically, which can be amended if necessary. , the physician may also choose to pay by check or electronic transfer to his account. Can be done.

If the benefit amount is less than the doctor's usual medical costs, the shortfall amount will be provided.

In that case, the physician must provide the patient with the patient's credit card 15 or payment card 1. Step 5 allows you to choose whether or not to pay the shortfall amount. If the patient requests it, 1. stuttering The sound announces the appropriate credit or payment card number 15, which is The payment is entered into the computer 3 and payment is made appropriately from the patient's account 65.

Furthermore, the computer 3 stores other relevant data in the database record 8 related to the patient 9. record the diagnosis results and the amount paid to the doctor. In this way, the pla The database for ABCT is updated in real time at the time of treatment, and , the clinic itself is updated, albeit indirectly as a byproduct of financial transactions between doctors and patients9. I do.

The insurance benefit sponsor that provides insurance coverage for Patient 9, i.e. Employer 2, also The office management computer 3 can be accessed via the link 24. However, employment Patient 2 accessed file 7 for the ABC plan over a wider range than the doctor. can be used. (Except for the patient's medical records as discussed below) As mentioned above, the doctor Whether a particular diagnosis is covered by insurance, the amount of insurance benefits and other similar data. Only data can be accessed. On the other hand, Employer 2 uses the ABC Bran 7 database. have access to all data contained in the database. Furthermore, Employer 2 is attached to Employee 9. be able to update certain data regarding insurance coverage provided, e.g. Person 2 can add, change, and delete the name of the insured person as appropriate. Furthermore, employment User 2 can also change the type of diagnosis for which insurance benefits are applicable. Employer 2 is Unlike restorative plastic surgery to repair damage caused by an accident, voluntary facial plastic surgery The surgery is not included in the costs borne by Plan ABC7 and is the patient's own responsibility. can decide to become In such a case, Employer 2 would choose Plan AB. Change C's database record 7 to that effect.

Additionally, Employer A2 can audit the operation of its own Plan ABC7. For example, use the list of insured persons to determine whether an employee is eligible for insurance benefits. You can know information about. Furthermore, as mentioned above, the computer 3 performs diagnosis and treatment. When done, record the information. Employer 2 thereby receives such information. It is possible to search and evaluate the insurance claim activity of the employee 9. Employer 2 further Data can be used to perform detailed statistical analysis of claims activity and insurance plan expenses. can.

3-36 show flowcharts detailing the operation of the system of FIG. This will be explained after explaining the main system components in Section 2.

FIG. 2 is a general drawing of the main parts constituting a preferred embodiment of the present invention. The invention eliminates the need to determine eligibility before payment of compensation services or funds is authorized. Real-time dynamic information management and control system that must be It can also be used for other applications that require.

The next step is to simplify the real-time utility of insurance administration and medical information. The present invention will be explained in detail based on Part 3 to Figure 36. person 2 interacts with computer 3 in real time, updates database 6, and A plan eligibility determination module 30 that can obtain information from the database 6. have. The addition function 33 allows employer 2 to add new employees and their dependents. ＠Be added to the list of members eligible to receive medical services under the health insurance plan. can. The delete function 36 allows Employer 2 to mark Employee 9 and his dependents as eligible. Can be removed from the list. The deletion of employee 9 is due to voluntary retirement or non-voluntary retirement. As a result, this system can be applied to C0BRA operation mode in case of involuntary retirement. 39 to ensure compliance with the C0BRA. Employer 2 further examines whether C0BRA regulations42 are complied with and whether the continuation of the plan45 is It is possible to inquire whether the employer 9 desires it.

Employer 2 is concerned about what services the insurance plan provides to non-employed workers 9. Since there is a heart, the plan usage module 4th is the inquiry that Employer 2 can request a determination. Menus (Menus indicate options that can be selected depending on the nature of the task you want to perform. This is the field's terminology for screens. )I will provide a. Non-employed person usage module Neil 51 reports information on insurance plan usage by individual non-employed workers 9.

The health care worker module 54 reports usage by the selected health care worker.

The treatment usage module 57 classifies the usage of insurance plans according to the treatment and analyzes the usage status by age. The usage module 60 reports the usage status of the plan by any selected age group. Ru. Employer 2 further applied for the 11m insurance plan via reporting module 63. You can request various reports and task lists regarding the people you work with.

The plan design module 66 is provided by the employer 2 in the case of self-insurance or by the insurance company. It consists of four sub-modules that allow you to design and manage your plans. sub ・The module includes deductions 69, benefit amounts 72, modifications and adjustments 75, and other programs. There is a module for 7 days of Run Open Won.

The large amount and timeliness of the data collected makes this system It has important value as a utility. Information request module 81 is convenient Statistical data 84 and raw data can be accessed by subscribers according to their specific needs. access.

The medical worker module 90 is a sub-assembly for determining eligibility 93 for a patient's insurance plan. module and bill validation sub-module 99 and bill payment 102 Claims processing 96 is reclassified into Benefit inquiry 105 to determine how much will be paid, the patient's subordinate status, and the patient's latest information Patient record request module 10B, which provides data up to medical data, and medical A patient record update module 111 that allows doctors to enter medical information about recent visits. It consists of Payment of deficit by patient module 112 Any shortfall in the amount left after the amount is paid to the doctor can be settled at the office.

Salvation 2. Persons of Color Subdivision Abstract 114 provides a summary of patient subdivisions available in emergency care settings. provide This indicates if the patient is unconscious or if the patient is unconscious, or if the patient is in an emergency room with useful information for performing emergency treatment. This may be particularly useful when medical help is not available.

Financial information inquiry 117 allows an evaluation of the costs of a health insurance plan. fund The transfer 123 is a credit/borrow account for appropriate amounts related to financial transactions between patients and doctors. conduct.

Error handling 126 is a communication problem or a response by the session initiator. Regarding online sessions that may be interrupted due to the lack of It gives the system a preparation function. Error handling 126 is state saving code 129 and a state restoration code 132. With these features, In most cases, Serasilan can be reinstated once discontinued.

Block 300 of FIG. 3 indicates that the cardholder (i.e., patient 9) This indicates that the card 15) has been presented to the provider. The provider side is medical services. This term refers to the person performing the medical treatment, that is, the doctor or hospital. Block 210 This indicates that code 15 was read by "8610". '8610 '' is a program connected to the Datatroll 8610 computer terminal 18 in Figure 1. This is an abbreviation for linter 131. The equipment was manufactured by Butator Co., Mibutonka, Minn. It is commercially available from Poration. Block 220 indicates that the card is unreadable. If so, at block 230 the provider operator enters the patient's identification number, i.e. Identify the patient's Social Security Number (SSN) and ABC Plan 7 for insurance coverage Indicates that the patient code, which is a number, is to be typed.

Block 240 is a terminal containing the date of birth (DOB) of patient 9 and its relationship to the cardholder. This indicates that the data will be input to the machine. In this example, Adams himself is refusing treatment. Therefore, the relationship becomes “employee°°.” If his wife seeks treatment, the relationship becomes “spousal.” person”.

Blocks 230 and 240 are for patients whose names are listed in the insurance plan upper section 7. Identify patient 9 so that he or she can receive medical treatment and the imposter cannot receive it. .

Block 250 is the step of selecting from the table to state the reason for the visit to the doctor. one A table of the form has columns for four reasons: illness, prevention, pregnancy, or accident.

Different reasons for visiting the hospital can be covered by different insurances, so the reason for visiting the hospital can be different. It is important in processing insurance affairs. For example, Plan ABC7 is Mr. Adams' wife's pregnancy. is covered by insurance, but it does not apply to her daughter. Furthermore, due to reasons such as accidents legal entitlement to insurance plan benefits and special medical procedures are performed. There are things you have to do. For example, YES (Y) leading to block 270 This route indicates that the motive for visiting the doctor's office was an accident. Block 270 is , the computer terminal 18 makes certain payments on behalf of the patient 9 to Plan ABC7. This indicates that the applicant is urged to take procedures for proxy repayment that will give him/her the rights he/she has. For example, automatic The car insurance company will be responsible for the person with the same color 9 or Plan ABC 7.

Block 280 determines whether patient 9 has been previously treated for the current condition. It indicates something to be said about something. If no, patient 9 did not experience the symptoms. State the date, which is entered at block 290. As block 300 shows , another insurance plan, XYZ, may be responsible for the condition. For example, my wife is also covered. I am an employer, but I am covered by my husband's insurance plan for which I am primarily responsible for paying. i.e., patient 9 and his wife's insurance plan pays for the husband's insurance plan. This is the case when the insurance plan is of a type that requires payment responsibility only later. block 3 20 indicates the stage where the name of the provider (i.e. physician) is selected from the code table. Ru.

Until block 330, communication with the office management computer 3 has not yet taken place.

However, at block 330, the clinic's local terminal 18 makes the local telephone call. Block 3 40 and 350 until the host computer 3 and the local terminal 18 are connected. Indicates that the user should try to connect.

Blocks 360-420 in FIG. identify reasonable accesses that occur on communication lines, and detect line noise (line noise is Sometimes, for example, the term refers to static disturbances. ), or “timeout” ( Reimout means that the part of the terminal 18 that started the session does not start up. prompts the host computer to terminate the session with the remote access terminal. This is a term relating to automatic functions performed by the controller 3. ), the current session The subscriber (provider or other reasonable user of the host computer) who initiated the (called a subscriber) is idle from a previous session. Ru. These blocks will be described in further detail in connection with the error handling functions.

When communication is established between the provider terminal 18 and the host computer 3, the host computer The computer 3 evaluates the transaction code received from the subscriber. for providers In this example, control continues to block 480, which transfers control to block 480 of FIG. Proceed to block 530. Figure 8 evaluates the various functions requested by the provider, and in this case Since this is a determination of patient 9's qualifications for medical services, it is determined whether patient 9 is qualified or not. It must be. Block 550 determines the need for qualification verification and directs control. 20 block 640.

Block 640 is a key (a key is a unique address of data in a database). A term related to data used when communicating with other data to describe Ru. ) based on the identifying information entered by the provider. Retrieve records from real-time database 6 of. Blockro 50 is social insurance Health insurance number (SSN), patient code, date of birth (DOB), and relationship with cardholder Compare information. At block 660, if the SSN and patient code do not match, If so, please reinsert the ID card into the provider terminal 18 or enter it as entered. I am not a member of the insurance plan with the SSN and patient code, so I called the auxiliary line. A message will be displayed instructing you to do so. SSN and user code match If so, control continues to block 680 and checks the DOB and cardholder relationship. A check will be performed. If one or both of these identifiers do not match, block At lock 690, a message to that effect is displayed on the provider's terminal 18. . If the provider decides not to re-enter the required information, block 700 causes the system to command to terminate the session. Meanwhile, the provider re-enters the data If you decide to do so, you can correct it by transferring control to block 240 of FIG. Enter data up to three times via block 710 until the desired data is obtained. be able to.

If the SSN, DOB, and relationship with the cardholder match, Patient 9 is an impostor. means no, control continues to block 720 where the real-time data The eligibility status is retrieved from the database. Information obtained at block 720 This leaves the provider with no questions regarding patient 9's qualifications. Patient 9 has insurance If the patient is still employed by the plan sponsor 2, the patient will have full insurance coverage. The status is reflected in the information obtained by the provider. possession of card whose employment recently ended and the cardholder wishes to continue the health insurance plan at their own expense. If you do not declare your intention to apply for insurance, a pending status regarding insurance plan benefit eligibility may be proposed. This will be communicated to the donor. (More on this important mechanism below.) Block 73 0, the system indicates that the reason for the visit entered in block 240 of Figure 3 is insurance plan AB. Check whether you qualify for C (i.e. whether insurance benefits will be paid) In order to search for insurance plan application information regarding Plan ABC7.

Additionally, whether your insurance plan will cover your diagnosis (i.e. wrist sprain) Judgment will be made at the time of.

If the reason for the visit applies, the transaction (i.e., 1) A certification code is assigned. Certification code as eligible to be treated A unique number that unmistakably identifies a transaction. Certification code is for other transactions Similar to the serial numbers on invoices, they function to facilitate bookkeeping.

Block 570 creates a qualification examination record that is opened in the office management computer 3. Ru. This pre-codes the data to be retrieved later by the doctor after the procedure is finished. It means to preserve. Block 760 is the doctor's terminal where the qualification examination record is stored. 18. In most cases, this is covered by insurance. In addition to confirming that the wearer 9 is covered by the This shows that. However, the temporary status of the card holder is such that insurance benefits will not be paid. is not guaranteed, and to avoid non-payment, the physician must Indicates that medical expenses should be received from patient 9.

At this point, the doctor has information that indicates that the treatment for the diagnosed condition will be covered by insurance. ing. As shown in block 790 of FIG. 3A, after the procedure, the physician may Enter the certification code into the terminal 18. Block 800 and block 810 are Local terminal 18 searches for Patient 9's name, Adams, finds it, and completes the transaction. portion of the medical procedure can be completed and transmitted to the administrative computer 3. Which indicates that.

Block 840 is for the doctor to enter a code identifying the diagnosis (wrist sprain). It shows. Block 850 relates to the treatment of wrist sprains employed by physicians. The block diagram to Figure 3 shows that the doctor manually enters the “procedure codes” up to 10. block 860 and block 360 of FIG. This shows that the data is transferred to the office management computer 3 by the following process. successively In FIG. 4, control passes to block 480, which It is determined that the code is for the provider, so control passes to block 530 of FIG.

Continuing determinations cause control J to proceed to block 570, which indicates that this is the It is determined that it is a management request. Block 570 transfers control to block 870 of FIG. Transfer to. At block 870, the request is sent electronically to back office comviator 3. be transferred. Block 880 performs the claim validation in block 940 of FIG. Call a routine to run.

Plan ABC? The dynamic database 6 for the validation process at block 940 Serves as manpower for the initiation of cess. Thereby, the cardholder's employer Ensure claims are made for the most up-to-date allowable diagnostic and treatment procedures provided by really processed. Each element of the claim is evaluated and a determination of validity is made.

The diagnostic code is checked for validity at block 940 and if it is not valid, the The control step proceeds to block 950 where the diagnostic code is invalid under Plan ABC7. A flag indicating that the result of a particular evaluation is true or false. This is a term that means a sign or logic indicating that. ) is cent. The diagnostic code is It is under the control of Employer 2 and will be detailed later. Similarly, each element of the claim and flags are set according to the results of the evaluation until block 1040 is reached. or not set, block 1040 indicates that the entire claim is subject to the validation process. It is determined whether the stored in a database. If the request is inappropriate for any reason , block 1060 converts each flag indicating a problem into a corresponding message. This is then transmitted to the provider's terminal 18 in FIG.

Block 1070 returns control to block 890 of FIG. Determine whether the request can be processed, and if the request can be processed, control is passed to the block in Figure 32. Transfer to 1080p. On the other hand, there is no way to reject a claim during the claim validation stage. If there is a reason (e.g. inadvertently code the procedure to handle Mr. Adams' wrist sprain) block 900 indicates that the claim is not processed. It is determined that there is no such thing, and control proceeds to block 9fO, and An error message will be displayed at 8. Blocks 920 and 93 0 indicates whether the provider terminal 18 in FIG. 1 is communicating with the office management computer 3. , and also performs a checking function to determine whether a decision to amend the claim has been made.

Corrections are made and provided in response to the error message issued at block 910. If the party continues processing the claim, control returns to block 870 to Transfer a claim.

Block 1080 in FIG. 32 represents each diagnosis and treatment procedure for which Plan ABC7 is applicable. Calculate the amount to be paid and take into account the specific agreement between Employer 2 and the attending physician. (for example, medical expenses such as diagnosis of wrist sprain, anesthesia administered, immobilization with a cast, etc.), and A. Coordinate payments between the BC Plan and any other insurance plans applicable to the patient. Block 1085 shows the patient copayment amount (patient copayment and patient 9 is requested to pay. For example, Plan ABC pays the full amount for wrist sprains, but (e.g., only paying half the price for plastic surgery) and the deductions applicable under Plan ABC7. and these amounts will be deducted from the total benefit amount. Information contained in database 6 will design Plan ABC7 throughout the working day with online update capabilities. The most up-to-date information for employers to keep.

Block 1090 determines whether Plan ABC7 will pay Mr. Adams directly. If so, block 1100 sets the cardholder flag.

Block 1110 determines whether the plan will pay Mr. Adams' doctor and If so, block 1120 sets the provider flag. Block 11 At 30, the system establishes an electronic transfer with the party to whom benefits are to be paid (Mr. Adams or the physician WI). (EFT) and, if so, block In block 1140, the EFT flag is set. Block 1150 indicates that the payment is Determine if it is done in a routine and if so, block control 1160 and executes EFT. To perform the transfer at block 1160 A more detailed description of U.S. Patent No. 1 is incorporated herein by reference. No. 4,346,442.

Block 1170 determines whether EFT has not yet been adopted as a payment method. If so, control is transferred to block 1180. Block 118 0 transfers control to block 1220 of FIG. provider flag is set If so, block 1230 prints a check with the physician as payee. It will be done. If the cardholder flag is set, block 1240 controls to block 1250, and the check with the cardholder as payee is transferred to block 1250. It will be printed. This is because the office management computer 3 uses Plan ABC or the insurance payer himself/herself. means printing a check drawn from a bank account opened by.

The check is then mailed to the doctor or patient9 based on the financial agreement signed between the two parties. be done. Block 1260 returns control to FIG. 32, upon return from block 1180. , the system sets a flag at block 1190 and updates the record in database 7. Block 1200 continues by updating. Updating records in database 7 Mr Adams was diagnosed with a sprained wrist and the treatment he received included immobilization in a cast. This reflects the fact that The financial records of Mr. Adams' Employer 2 show that The invoice is paid and the payment is recorded as being by check. vinegar These are the check number, date, payee's name and address. Employer 2 plan records 7 is the services provided to Mr. Adams and the benefits authorized by the plan. amount, the patient co-payments owed by Mr. Adams, to be made in this transaction. Updated with deductions, name of physician providing services, and date of transaction be done. Recording of financial transactions is made via data 24 in Figure 4 to employer 2 or It can be used by any of the insurance payers.

Block 1210 creates a receipt, transmits it to the physician's terminal 118, and sends it to the physician's terminal 118. The billing processing routine ends through block 1215. Patient 9 was treated Sign your approval on the receipt. The benefit amount is less than the doctor's usual medical expenses. patient 9 is responsible for the deduction, or patient 9 is responsible for the deduction by administrative computer 3. It may turn out that the procedure is not covered by insurance, so the patient may have to pay the shortfall. I have to pay. [Doctor's terminal] 8 prints a receipt using the billing processing function described above. Fool 9 continues to communicate with office management computer 3 even after the Patients have the option of paying with credit card15 or withdrawing money from current account65. can be set.

Upon returning from the billing function, back office computer 3 executes blocks 530 and 530 of FIG. Another command from the physician terminal 18 is awaited as shown at 540 . Shortfall amount for one color person 33, control passes to block 565, which transfers control to block 565 of FIG. Transfer to lock 1263. Patient 9 uses credit card 15. If selected, insert the card into the physician's terminal 18 and block 1266 In response, patient 9 chooses to withdraw money from current account 65. If the block 1269 is the EFT routine of the block 1272, block 1269 is The credit card rules at block 1266 are transferred to Upon return from either the EFT routine in block 1 or block 1272, block 1 275 checks the transaction status to see if it completed successfully. confirm. If the transaction is successful, block 1278 is EF TI-Ranxion receipt or credit card transaction The credit card slip is transmitted to the doctor's terminal 18 and printed by the printer 131. Ru. Transaction rejected due to insufficient account balance or limit exceeded If so, block 1281 transmits the reason for the rejection. Block 1290 is Control'B is returned to the provider function of FIG. 8, at which point the physician selects another function or Senonran can be completed.

In addition to the above-mentioned determination of qualification examination and explanation of benefits, One of the key mechanisms is that physicians maintain a comprehensive medical record8 for each patient9. This is something that can be done. This is most of the ``backward search'' 　Traditional and financial tracking methods for various diagnostic and treatment systems It's better than pz.

(Historically, computer systems have been relatively distant in time from real events. Designed to keep track of events or transactions; It is called a retrograde search system. ) On the other hand, the office management combinator 3 The real-time data database 6 captures events as they occur. two separate events that occur relatively close to each other in time but spaced apart The value of this ability is immeasurable if it survives.

After Mr. Adams left the doctor's office, he was involved in a serious car accident on his way home. Assume that Mr. Adams is seriously injured and unconscious.

Mr. Adams' visit to the doctor's office revealed that he had a rare blood disease and needed a blood transfusion. It was determined that special measures would need to be taken if Mr. Adams' doctor The logical step is to update Mr. Adams' medical records before he leaves the clinic.

Mr. Adams is bleeding profusely from his injuries and requires a blood transfusion. For Mr. Adams Fortunately, he has doctors and hospitals all provided by administrative computer 3. Live in a community that subscribes to the service. A treatment room at a local hospital A review of Mr. Adams' medical records, made minutes after arriving at the hospital, revealed that Mr. information needed to save lives. Emergency room staff have patient card 15. is utilized to run the back-office management computer starting at block 200 of FIG. 3, as described above. access data 3. The information recorded on the card 15 can be read in a magnetic reading format or If it is not possible to read the Qi Strive, please read both the engraved formats on Card 15. You can take it. Furthermore, DOB and relationship information is recorded on the card. , emergency and treatment room staff can enter information even if the patient is unconscious.

Emergency and treatment room staff are subject to block 340 in Figure 8 and block 360 in Figure 4. n Access processes. The back office combinator 3 validates the log at block 370. perform a validity check to check if he is a valid subscriber, and block 42 0, it is determined that this access is not a previous Sensilan interrupt, and the control is Proceeding to block 430, the access is determined to be an emergency room referral. Set. Control passes to block 1530 of 11iN4A, at block 1530 11 Shimeya and medical records of 8 people of color were searched in the form of emergency case abstracts (2, the abstracts will be detailed later). 1540 to the emergency room terminal 18. record can optionally be printed as directed at block 1550 and block 156 At 0, a return instruction is issued and control returns to block 440 of FIG. Block 440? All blocks starting from A transaction processed by a “yes” branch at lock 500 The group is reset at block 510 and control is transferred to block 380 to Mr. Adams' condition to await orders was based on information provided by a doctor he had previously visited. real-time medical care in cases like this that otherwise would not have been discovered. The value of data is immeasurable.

Some time ago, the online real-time data What used to be a pipe dream is now possible. The effectiveness of the invention is seen in the context of today's clinics. Bringing reality to paint-of-contact data management Is Rukoto.

At the same time, it can optimize medical practice. Optimal for medical practice ``A caseworker of the triage-type of wounded soldiers Use captured data to ask questions and re-examine patient wants and needs. It also includes doing.

Supplemental information on Wounded Soldier Classification Formulas and Point Contact Data Management is incorporated herein by reference. ``Point-contact data tube'' by Dr. Noeferi G. and Kablan, cited in Described in Physical System Theory J (1989, published by Medical Sou Z! Faith) ing.

The doctor Adams visited as described above did not receive any medical attention even after the patient's claim was processed. 8 and the physician is blocked from updating the patient's record in Figure 8. 560 to continue the session. Block 5604 Control is transferred to block 1300 of FIG. At block 1300, the SSN, Patient 9's medical records are retrieved using the employee card, DOB, and relationship with the employer as search keys. Record 8 is searched. Once the search is complete, the records are transferred to the physician's terminal 1 for viewing and updating. Transmitted on the day. Doctors evaluate laboratory results, prescribed medications, injections, and patient symptoms. Update medical records with patient information, including post-illness treatment recommendations. Doctor voluntarily Print record updates for hospital files as directed by block 1325 You can also. After updates are entered and possibly printed, the record is The data is transmitted to the office management computer 3 via the data link 21, and updated in block 13. 30, it is stored in the data cache 8. Block 1340 returns to FIG. The master can end the Senon Run by requesting the “quit” command. .

By combining the capabilities of the office management computer 3 and online data storage 6, Physicians can choose to reduce the amount of records they keep in their offices. Office management computer Electronic medical and medical records maintained by Data 3 are kept in patient records in the clinic's filing cabinet. It is possible to eliminate the situation where the records are full of documents. Thereby clinic records This not only reduces or eliminates the need to maintain administrative Built-in safety mechanisms and disaster recovery procedures maintained on computer 3 ensure records are always available. It is also guaranteed that it can be used.

Continuing with the Foolish Mr. Adams9 example, a second opinion is required before treatment is approved. This is often the case. Mr. Adams came to the hospital for treatment, and the doctor told him whether he needed any acupuncture or moxibustion. If the doctor does not visit the hospital, the scenario is as follows. Physicians use patient's resources Follow the steps described above starting at block 200 of FIG. . However, there are cases where the doctor first wants to know the fool's doctor and the medical information 8. This is a diagram instructing the administrative computer 8 to access the patient's record 8 at 8; This can be achieved by This request is processed via block 590 of FIG. The block transfers control to block 1350 of FIG. Pro, Ri1350 is a patient. Search for a person's health records, medical records, or delete menu options to cancel this request. Spray. Block 1360 accepts the selected option and blocks 1360 Determine whether to proceed to 370 to end this processing step or continue searching for records. do. Assuming that a search for records is selected, block 1390 retrieves the patient's records. Search for record 8. Block 1400 displays the patient's record 8 on the physician's terminal 18. The doctor then prints out all or part of the selected record using the printer 11 of the terminal. can do. Processing is again blocked by a decision to continue at block 1420. Return to 1350 or timeout block 1430 if no decision is made. The error handling function terminates the process via the error handling mechanism of FIG. At block 1420 Following the normal path of continuing processing, the physician enters the menu at block 1350. Select “Exit” to end the record retrieval process and continue to block 1380. After that, we can return to FIG.

After Mr. Adams' review is complete, the physician can receive the proposed benefits by inquiring about the benefits. Tell Mr. Adams how much the patient will need to pay for the procedure. Blocks in Figure 8 580 transfers control to block 1440 of FIG. At block 1440, Plan ABC's diagnosis and treatment records 7 are searched to diagnose and recommend Mr. Adams' case. The code corresponding to the action taken is checked. If the code provided is incorrect nO” branch is taken to block 1460, where the error is displayed. , a request for modification is made. Blocks 1470 and 1480 go to error message response or non-response and branch accordingly. Is the code provided valid? If so, control continues to block 1490 where the physician's diagnosis and suggested The worker's insurance plan records7 are retrieved to calculate the final medical costs for the procedure. It will be done. At block 1500, actual calculations are performed and the results are stored at block 1510. The information is transmitted to the doctor's terminal 18 as shown in FIG. Block 1520 transfers control to FIG. return.

The doctor compares the usual medical costs with the benefits transmitted by the inquiry and uses this information. Tell patient 9. In addition, the patient co-payments that the patient 9 is expected to pay under the insurance plan. The amount will also be queried.

Specialty determination system, personal diagnostic tests, referral of patients to various specialists, and other information Improving the effectiveness of medical communities by leveraging information-oriented computer technology The potential to improve your business starts with a systematic and systematic acquisition and search of data.

H.

R. Herry, whose paper is cited herein as a reference, ``Fourth Generation Management.'' ``Medical Care'' (included in the July/August 1989 issue of Rainbow Ω Practice 2 Eni 9 Fire Magazine), a comprehensive These and other uses of database 6 are explored.

The above description, which focuses on the provider-patient transaction process, is not realistic. It has a "closed loop" relationship that only the time system can effectively control. . Other “closed-loop relationships requiring IJ real-time update capability include Relationships between sponsors, health care providers and employees, and patients. Table 1 shows the administrative By the management computer 3, 1! This is done by connecting to the business management computer 3. This is a summary of the order of steps.

Wheat--1 1. Mr. Adams 9, his spouse and dependents will be deleted from the list of insured persons 7.

2. Insurance coverage has ended for Mr. Adams9 and possibly other dependents. Notify. They have the option to continue coverage of a particular insurance policy at a given premium within X days. Notify you that you can choose. Send these notices 40 by certified mail. do.

3. If the notified person answers that he/she will continue the insurance within the specified period, periodic Print and send a package of payment coupons 50 for payment.

4. If no response is received within the specified period, the database for insurance plan ABC Record this fact in the

5. (Optional) If the answer is not accepted as in paragraph 4, please send the optical subscriber a second The additional notice 40 is printed and sent.

The first row of Table 1 shows that Mr. Adams' family 9 is covered by Plan ABC due to termination of the employment relationship. indicates to be removed from the insurer's register, this is done via data link 24. directly by Employer 2. The importance of being removed from the list in this way One of the key results is that if a physician makes a query using Physician Data Link 21 , Computer 3 tells the doctor that Mr. Adams' family 9 does not have insurance plan ABC. The computer 3 immediately has information that can inform you that it is no longer valid. It is to be. However, in the same case, as will be explained later, computer 3 The family refrains from notifying the family that they are no longer covered by the insurance plan; It is also possible to notify that the application is on hold.

Addams Family Participant 9 was removed from the insurance plan and Employer 2 If requested earlier, the office management computer 3 starts the printer 170. The printer will notify the family of the termination of insurance coverage and will notify the family of the termination of insurance coverage within a specified period of time. Being able to choose to enroll in the same or similar insurance that you previously enrolled for a fee. Print out a notice 40 presenting the details and send it to the family member or family members. 6 Notification 40 was sent to Mr. Adams' family 9, after which computer 3 was Set in programming routine, if answered, Mr. Adams' family Track answers from 9.

If one or more members of Family 9 respond in writing to continue, the operator The data enters appropriate data into the office management computer 3. In response, Computer 3 uses printer 170 to print a group of payment coupons 50 and This will be mailed to subscriber 9 who has chosen to continue. Subscriber 9 periodically clicks with payment. Disguised as a coupon, this coupon is used to track the progress of payments for subscriber 9 who chooses to continue. It assists in tracking by the management computer 3. Coupons Enough to Do That information is recorded, and as is well known, it can be machine read by the office management computer 3. It is possible to remove it.

If no response is received within the specified period, the internal clock The computer 3 equipped with this notifies the database 6 for plan ABCT of this fact. , a program to change the status of Mr. Adams' family 9 from pending to terminated, as described below. program is executed.

As mentioned above, Mr. Adams' family members9 were given the option to purchase insurance within the specified period. Options may be suggested. This option may be subject to collective bargaining agreements, state or federal law enforcement, or Other reasons may also be suggested. Furthermore, this option is limited to a certain level. There may be aspects of legal recourse. For example, an employer may and grant the right to exercise the option within a specified period of, for example, 60 days. If the zero option that may be sought is retroactive, the following steps may be taken: Ru. Notice 40 that the employment was terminated on July 1st was sent on the same date, July 1st. The notice 40 to be attached was received by employee 9 on July 2nd and the letter 40 was Memorandum 40 gives him 60 days to decide whether to take out insurance. I can do it. Employee 9 may visit the doctor's office on July 15th, but this is not his option. before exercising. He exercised his option on July 20th and paid the required premium. If you pay, ABC Plan will provide insurance benefits for your hospital visit on July 15th. Sometimes I get caught. Therefore, the office management computer 3 is When searching the Plan ABC database 6 in response to the 9 as pending until the exercise of the option or the expiration of the option period.

Continuing with the same example, the election deadline expires on September 1st without exercising the option, and Adam If Mr. Su 9 visited the clinic on September IO, the office management computer 3 would be accessed by the doctor. According to Mr. Adams 9, insurance coverage for the ABC plan has ended and there is no pending status. I will tell you something. Furthermore, within the designated period (60 days in this case) after the mailing of Notice 40, The classification was immediately performed by the computer upon the expiration of a certain option period. It becomes.

Some important aspects of the invention are as follows.

1. As shown in Figure 1, Employer 2 uses data link 24 to add Beneficiary 9. and deletions, and changes to the terms of the insurance plan (e.g. Plan ABC). I can do it. Furthermore, as the previous discussion shows, these changes can be made in real time. Therefore, the current state of database 6 depends on the diligence of employer 2. limited. The fact that database 6 is up to date has two important implications: First, the average delay period of 15 days mentioned above is eliminated. follow Former employee 9 took advantage of the delay period to receive insurance-covered treatment. and become unable to do so. This is because the doctor who performs the treatment must have a list of employees who are insured. This is because you will be able to immediately know that the content has been deleted from the website.

The second result relates to the requirements of the C0BRA legislation. For example, a known detection may trigger the implementation of the aforementioned notification procedure. The routine detects a deletion from the roster and immediately responds to it as outlined in Table 1. A notification will be sent to you. With this instant notification, C0B Insurance benefits stipulated by the RA regulations are prevented from being provided at the expense of the employer2. Ru. These two outcomes both limit the employer's liability for costs due to the passage of time. They are similar in that they are defined. From another perspective, when insurance coverage ends, The same event that eliminates the 15 day delay (i.e. real-time deletion from name 1) The notification procedure in Table 1 is also triggered by

2. The patient's medical expenses are calculated as described in connection with block 1085 of FIG. calculation of deductibles to be borne by Mr. Adams, and if Mr. Adams is covered by multiple insurance policies. This includes calculating allocations between overlapping insurance plans if applicable. The reason why it is possible The reason is that the administrative computer 3 keeps records of all insurance activities by the patient Mr. Adams 9. and maintain records of coverage and extent of coverage under one or more separate insurance plans. This is because they have it. For example, Mr. Adams9 has a benefit deduction of $100 per year. Mr. Adams9 has not received any other medical treatment in the past year, and If the installation cost $80, the full $80 will be paid by Mr. Adams9. . Similarly, Mr. Adams is covered by the XYZ plan through his wife's employment. plan XYZ covers some or all of the medical expenses, including deductibles or You may have to pay a portion. These facts are printed by the terminal tree 18 in FIG. It will be written on the slip.

3. The explanation so far has been given in the context of a patient visiting a doctor. However, the original Akira is a medical practice that includes doctors, dentists, hospitals, pharmacists, podiatrists, podiatrists, and psychotherapists. It will be appreciated that it is available to any health care practitioner providing the service. In this aspect and whether the provider is authorized to perform the procedure for which payment is being made. You can also add programming routines to check whether For example, a podiatrist are prohibited by state law from performing certain surgeries. What a medical professional can administer A list of possible treatments is stored in the office management computer 3, and the name of the medical practitioner is shown in Figure 4. The search is performed at the time identified in block 360 of . Unauthorized by this routine Insurance payments to medical professionals will be prevented.

4. The card 15 in Figure 1 held by the patient is used by the patient regardless of the type of medical care being requested. It is the only card used by In other words, the patient is not a dentist or a podiatrist. The same card should also be presented to psychological therapists, etc.

5. Between the doctor's terminal 1st and the office management combiator 3, and the office management computer The telephone connection between computer 3 and employer 2 has already been described. Preferred telephone connection Next is Tamlet, which is commercially available from McDonald's Douglas Corporation. It uses a well-known communication 7 notebook such as . This network Physicians in one city can call toll-free within their local area to see if they are in another city. can communicate with the business management computer 3.

6. The patient recently retired and has since returned to the medical clinic! If the The computer records the patient's insurance status as pending, as outlined in Table 1, and informs the physician of this. I'll tell you. In such cases, Plan ABC will not be involved at this point and your doctor will must decide how to make payments.

7. Up until now, the present invention has been described in connection with health insurance claims. But this is generally applicable to any insurance plan in which a third party pays costs on behalf of the beneficiary. It is. An example of this is the food stamp program, in which Beneficiary transfers food stamps (i.e., corresponds to “card” 15 in Figure 1) to supermarkets. The provider uses the terminal tree 18 to verify that the stamp is valid. and whether the beneficiary is eligible to use the stamp. can be done. In this case, the list is food stamp beneficiary's first name.

In another example, the public employee compensation program is treated as similar to Plan ABC. and make the payment.

8. Utilize additional steps in addition to the above verification steps to verify the patient's name It is also possible. As is well known, there is also an n-certification procedure based on voiceprint, consultation, and signature verification. It is possible.

9. Up until now, Plan ABC has been explained as an insurance plan. But not necessarily It doesn't even have to be an insurance plan. Plan ABC can also be an employer's self-insured plan. It may be any plan that protects the beneficiary with respect to specific types of medical care.

Employer 2 controls the dynamism of the invention, i.e. in preserving its utility. Essentially, the employer plays a central role in (1) patient management under the employer's Plan 7; (2) determine the patient's rights based on the plan design; Close the information loop between patient 9 and provider by retaining data that . The following description of the flowcharts related to the two important functions mentioned above provides details of the actual processing steps. The details shall be disclosed.

FIG. 35 shows the process for accessing the office management computer 3 via the data link 24. It shows the process. Block 1570 includes selecting Log from the procedure menu. Person 2 is shown. At block 1580, the employer enters a password (password). A password is a secure system used to restrict access to a specific system to only authorized people. This is the terminology in this field for the combination of letters and numbers used in all devices.

), access certain system functions authorized for a given password. Block At 1590, Employer 2 selects a specific function from a menu of available and authorized functions. Select. Block 1600 transfers control to block 360 of FIG.

If there is no connection, block 1620 allows the employer to access the process. You can try accessing the access again or exit there and try accessing it later. .

Figure 4 can be provided depending on who the subscriber is, as mentioned above, and also from the function menu. It decides where to branch depending on the transaction code received. descriptive Assume that Employer A2 intends to retain the qualification screening function for a reason. Ru. Various decision points lead to block 450 where insurance plan funding is determined. If the transaction code is recognized and the “yes” branch is taken, the control proceeds to block 1630 of FIG.

Figure 5 processes a validation request submitted by Employer 2 and directs control to a specific function. Proceed to the submodule that executes. Blocks 1630 and 1640 are It functions to monitor the activities of the terminal. Controlled by request from employer a2 The control proceeds to block 1650, where the request is made to the employee on Plan ABC7. The applicant will be evaluated for inclusion on the list as a qualified employee. employer a Assuming that 2 is adding a new employee to the roster, the “yes” branch is controlled. control is transferred to block 1750 of FIG.

Block 1750 advances control to block 1770 where employer a2 Various demographic and personal information about the user can be entered. block 1 780 allows information to be entered for each of the employee's dependents. Bro check 1790 determines whether any modifications are required and, if so, , retransfers control to block 1770. “nO” if no modification is required The branch reaches block 1800, and database 6 is transferred to the new ABC plan name II 7. Updated employee information for each new patient eligible for Plan ABC7. Create record 8. (New patient records are stored on the administrative computer by the new employee.) It is assumed that the insurance plan does not apply to insurance plans belonging to category 3, and if this is not the case, If so, patient records can be transferred from the previous plan. ) block 1810 The “end” command is issued and reaches block 1820, and block 166 of Ward 5 is reached. Check whether it returns to 0. If not, branch to block 17 50 and a new employee is added again.

Returning to block 1660, FIG. Follow the 'no' branches of successive decision blocks until reaching block 1720 The “yes” branch leads to block 1730, which resets the flags related to processing the command. set. Control then returns to block 1630 where the additional request is over-evaluated. Restart the process.

Next, assuming that employer a2 requests the deletion function, the decision mechanism makes an evaluation. , control is passed to block 1830 of FIG. 11 via the "yes" branch of block 1660. and forward it. Blocks 1830 and 1840 contain the well-known "commandable" and " "timeout" mechanism begins processing. The command request was issued by a previous module. control proceeds to block 1850 to determine if the termination was involuntary. It is determined whether Assuming an involuntary termination, block 185 A “yes” branch of 0 advances control to block 1900 of FIG. 25. Not voluntary The consequences of termination are determined by the employer's contractual obligations and by government-required program requirements. The invention may vary from employer to employer and from time to time depending on the changes. Comply with the provisions of the above-mentioned C0BRA legislation required by the government.

Block 1900 changes the employee's health insurance coverage status to a provisional pending notification status and accept or decline the option of obtaining health insurance coverage from your employer. Set it to either. Block 1910 indicates that this employer's response time is , the employee must respond to the decision by then, and the employer will provide insurance benefits. Set to count down the acceptance period during which legal obligations remain . Block 1920 is for employees whose insurance coverage has terminated and those formerly covered by the insurance plan. Print a notice to other persons entitled to exercise their right to choose. for example, Spouse and/or other dependents covered by the employee's insurance plan If so, they are terminated regardless of the employer's decision to terminate coverage. You have the right to choose health insurance coverage.

Block 1930 stores database 6, ABC Plan employee list 7. Update pending status for employees and their dependents whose insurance coverage has ended. installed The clock function begins counting down the selection period. This information All of this is done as soon as the employer enters the deletion instruction for the terminated employee in the database 6. is memorized. As mentioned above, if a terminated employee receives health insurance services, Attempts at The health care provider is alerted to the fact that he or she must perform all the procedures themselves. Bro Block 1940 returns control to block 1860 of FIG.

Decision blocks 1860 and 1880 both take the "no" branch and block control. Return to 1830. If you need to handle voluntary termination, the decision block should be The "yes" branch is taken at block 1860 and block 1870 is executed.

Voluntary termination by the employee typically provides coverage to the employee and his or her dependents. Employers are not obligated to maintain coverage. In such cases, termination health insurance benefits may be canceled immediately. Therefore, the employer There are no additional costs associated with the costs of However, C. warns that this does not apply to employees who are voluntarily terminated. No one takes any risks either.

Block 1880 ends the deletion process and returns via block 1890 or At check 1830, it is determined whether to continue. Assuming that a termination command has been issued, Control returns to block 1670 of FIG.

Remaining in the functionality shown in Figure 5, control returns to the program 1630 where the The person then issues a plan utilization inquiry command. This decision block controls block 1 670, where the ``3'es'' branch transfers control to block 1950 of FIG. Proceed. Figure 12 basically evaluates the options available in the plan utilization module. , and branch the requested function.

Plan usage module allows employers to view current plan usage on an as-needed basis By doing so, we provide an extremely useful tool for employers. This feeling The information will subsidize the current shortfall in the current plan and if the current plan is being abused. Six selected options will assist you and serve as material for designing future plans. are indicative of the types of queries that are possible and in no way limit the utility of the invention. It's not something you do.

Assuming that a plan usage inquiry request is made by an employee, the control Proceeding to block 2060 of FIG. 26, in block 2060, employer a2 Enter the employee's name and SSN. Block 2070 is processed for the employee Search employee records containing raw data for each transaction made. this includes not only the employee's transactions, but also all transactions for the employee's dependents. It may also include transactions. Block 2080 retrieves the source data and The total costs incurred for each dependent in an effective manner and the corresponding dependent's insurance plan. Aggregate the raw data to obtain a chronological classification of run benefits.

This report is printed on the employer's peripheral printer 180 as shown in block 2100. or voluntarily downloaded on the employer's terminal 11185 based on the professional report 2120. be sprayed. Once the employee has completed the inquiry regarding plan utilization, Employer 2 The termination command thus issued returns control to block 198o of FIG.

The operation of the inquiry function by provider, processing and age is based on the above-mentioned employer shown in Figure 26. The operation is similar to that of a query. The flowcharts for these three query functions are shown in Figure 2. 7-29.

Returning from FIG. 12 to block 1680 of FIG. The request is then returned to block 1630. Employer 2 inquires about C0BRA and legal compliance Assuming that , control is passed from block 1680 to block 2 of FIG. Proceeding to 500, block 2520 performs a search for records and determines if there are any records. Control returns to block 2533 to determine; if no record exists, block 2536, the employee did not elect to continue with the plan or had the option to do so. is not exercised within the election period and the employee is removed from the roster. set. Block 2540 indicates whether the original employee is still within the election period. Check. If this is not the case, the administrative computer 3 Display that the 0BRA legislation does not apply or that the provisions have been implemented. , control returns to block 2500 for Employer 2's other inquiries. the employee If it is within the selection period, control returns to block 2560 to determine the employee's insurance coverage. Determines whether notices have been sent to all persons affected by the termination of . If the notification has not yet been sent, block 2570 sets the notification flag to is set to "no" and control passes to block 2580, which ends. Determine whether the response from the employee who has completed the If so, control continues to block 2640 of FIG.

Block 2460 indicates to Employer 2 whether the employee's response is to continue the plan or not. A response of 0 indicates whether the applicant chooses to continue or does not choose to continue. If not, the employee's record will be removed from the plan roster and this determination Descriptive items and audit trail report are written in the report. (What is an audit trail report? Indicates that an important event has occurred, such as a record being deleted from database 6. This is a report. ) block 2660 returns control to block 2590 of FIG. , block 26 if the employee's response is to continue with the plan. 70 retrieves the former employee's record from Plan ABC's directory. block 268 The payment schedule is calculated with 0. Block 2690 reflects that continuation has been selected and update plan name 17. Block 2700 is the payment sent to the former employee. Print the payment slip and block 2710 returns control to process 2590 of FIG. . Block 2590 determines whether additional secondary notifications have been sent and If not, the chasing flag is set to "no". block 261 0 displays the current status of the former employee based on previous evaluations. This dis The play includes notifications, secondary notifications, accepted answers, and selection decision status.

Block 2620 determines whether the employer has finished the inquiry and, if so, returns control to block 1690 of FIG. If not, control rests with the employer. Proceed to block 2500 for the next input.

From FIG. 13, control passes back to block 1630 of FIG. Assuming that the function is selected, the decision block transfers control to block 1690. The block then passes control to block 2720 of FIG. Report and work list The striker obtains information in a medium useful to the employer in order to carry out some preliminary work. It is a convenient way to Figure 14 shows how to properly prepare a standard work list or report. It shows Mr. B who can be created. This process allows employers to handle non-recurring issues. Cases where information is required are supplemented by special reporting capabilities.

Suppose an employer requests that a health insurance plan be audited. Lock 1695 transfers control to block 2880 of FIG. Plan audit An infinite array or combination of factors can be assumed depending on the results of the preliminary inquiry. . To facilitate this kind of approach, this module uses predefined illumination. Audit criteria can be dynamically selected. 2900 can be used in the B-hat of “-hat if” to perform plan audits. Displays a menu of parameters. Block 2910 is plan data Sweep the base 7 (a database sweep is a sweep of a particular record in database 6). It is a term that refers to the process of examining all records. ), selected para Select the record that corresponds to the meta. Block 2920 calculates the result and blocks 2920 as displayed at 930 or optionally displayed at block 2940. Create a report so that it can be used. If the employer decides to terminate, the Block 2950 transfers control to block 2960, which transfers control to block 2960 of FIG. Return to lock 1700, if employer does not terminate, IIIWl is block 2 Returning to 880, additional auditing can continue.

The plan audit feature has no lag time in transaction processing, so dynamic alliances This is an important mechanism for recognizing that caution is required. The frequency depends on the individual employer. It is useful to know that this capability can be utilized on demand, depending on the decision made by the It is.

Returning from FIG. 36 to FIG. 5, control proceeds to block 1630, at which point the termination request is issued, block 1700 transfers control to 1710, which blocks the Control is returned to block 460 of FIG. Decision blocks 460-490 are "no" Takes branch, but 500 because previous transaction request has already been processed Branch to “yes”. Block 510 resets the transaction completed flag. and sends control to block 380. This block is an additional transaction Monitor acceptance of requests.

In our example, Employer 2 is self-insured and has no questions regarding the design of a health insurance plan. In such cases, the appropriate transaction code takes control from block 4. Step 60 Block 460 then passes control to block 2970 of FIG.

FIG. 6 determines the nature of requests that fall into four categories. Employer A2 pays deductions and prescribed medical examinations. Changes in the amount of benefits to be paid for the treatment or correction of the amount paid or can make adjustments and catch all the range of different plan choices.

Blocks 2870 and 2980 evaluate the existence of a new request and if the request is received. , control continues to block 2990. Block 2990 indicates that the request is to change the amount of the deduction. Determine whether the If so, block 3000 2 allows you to enter a new deduction amount, and this deduction amount will then be applied to the ABC plan. Record 7 previous deductions and! Can be replaced. Additionally, an audit is performed to remember this event. Records are written. Control B continues to block 2970.

If the request was to change the payable amounts for various diagnoses and treatments, the control would be blocked. Proceed to 3010 where the “yes” branch calls block 3090 of FIG. , control passes to block 3110 with the new request, so blocks 3090 and 3100 requires no explanation. Block 3110 calculates the amount of salary for employer a2. Request that you manually edit the processing code you are trying to change. Block 3120 selects The record corresponding to the selected code is retrieved. Block 3120 records and current Display the benefit amount. At block 3130, the new benefit amount is entered and confirmed. A request for is issued at block 3140. Block 3150 indicates that the record is correct. Determine whether it has been confirmed. Otherwise, the “no” branch is taken and the control returns to block 3130 to enter the revised amount. Records are correct If so, block 3160 updates the record of Plan ABC and remembers the change. The termination command at block 3170 transfers control to the blocks of FIG. Return to lock 3020. If no termination request is issued, control passes to additional update requests. Proceed to block 2970 to do so.

Returning to FIG. 6, decision blocks 3020-3040 follow the no'' path.

Since the previous request has been processed, block 3060 branches to "yes" and control transfers to Proceed to block 3070 to reset the request code flag. Then the control is Returning to block 2970, a new request is received.

If payment records need to be corrected or adjusted, this function requests control. Proceed to block 3020. Block 3020 takes the "yes" branch and directs control to Proceed to block 3190 of 16. Since this is a new request, the control 3210, where the name of the plan member whose record needs to be corrected or adjusted. and SSN are input. At block 3220, the plan member's records are retrieved.

Repair transactions delayed or problems discovered by block 3230 Enables entry of adjusting or modifying transactions in order to (The above problem is If the action code is incorrectly processed, the person is responsible for acting on behalf of the person's rights. delayed transactions where payments need to be adjusted as a result of It may occur due to this. ) Confirmation is made at block 3240 and the block If no confirmation is made, block 3250 returns control to block 323o; If approved, return to block 3260. Block 3260 is Plan ABC Update the transaction record to the plan member's record in 7. block 327o determines whether to continue to block 3190 or return to FIG.

After employer a2 completes the modification and adjustment functions, control n returns to block 3030 of FIG. , and finally to block 2970, where the employer then opens another plan. If the town is requested to be changed, control continues to block 3030 where this block The lock advances control to block 3290 of FIG. Previous features plan design properly describes the mechanisms for modifying the plan and performing routine maintenance of the plan. Therefore, FIG. 17 will not be described in detail.

The preferred embodiment of the present invention defines the range of data within database 6 and each transaction. From the perspective of data freshness due to real-time updates performed in It has clear advantages over other technologies. This makes the data itself commercially valuable. It becomes a resource with value. This aspect of the invention requires medical data for various purposes. , was developed to provide information to paying subscribers.

Government agencies and private organizations often require data on disease identification and management. stomach. Traditional methods of collecting such data are time-consuming and costly. Early detection of diseases and abnormalities allows for treatment or isolation of pathogens before they spread. 9 Great Contributions This invention provides timely data, so you can enjoy this at a reasonable price. It is advantageous for various institutions to subscribe to services that access data . By providing data in a timely manner and at a fair price, These institutions will be able to allocate more prize money to treatments.

In addition, individual group members can access their personal files and track their final checkout, for example. You may want to know how much time has passed since then. Cash in places like public libraries It would also be possible to install payment terminals.

Subscribers to information services use standard personal computers to provide administrative control. can access computer 3. Access between employers as outlined in Figure 35 The procedure is basically the same for subscribers to information services. Just log on 4 calls the information retrieval capabilities of block 3390 of FIG. Instruct the control mechanism. Figure 7 has already been explained as a means of selecting one of N options. As I said. However, the information subscriber has three options in FIG.

In other words, search for statistical data or original data, or go to the office management computer 3. You can choose whether to terminate access. If subscriber selects aggregate data Control then passes through block 3410 of FIG. 7 to block 3480 of FIG. .

Block 3480 of FIG. 18 displays a menu of statistics options.

This is basically a list of specific types of calculations that the subscriber wishes to perform. .

(For example, mean, median, standard deviation, frequency distribution, regression analysis, etc.) The check 3490 searches through the options selected by the subscriber and selects the option that the subscriber wishes to exit. At block 3500 it is determined whether a selection has been made. If the selection is finished , the 'yes' branch of block 3500 leads to block 3510 where control transfers to Returning to block 3420 of FIG.

If the selection is not complete, control continues to block 3520 where the second menu 2. Determine which data are suitable for entering the population being studied. Display parameters. (This can be as simple as specifying the age group. , all males under the age of 12 whose father has hypertension and whose mother is a diabetic who smokes. Even something as complex as selecting a child would be possible. ) block 3530 is a para Search the meta and block the control to determine if the exit option was selected. Proceed to lock 3540. Assuming termination is not selected, block 35 60 reads the data base 6 and selects data from records that match the population criteria. do. Block 3570 performs the calculation selected in the first menu and returns the result to The data is sent to block 3580 where it is displayed. block 358 5, a hard copy of the calculation results is optionally printed. block 3590 and 3600 executes a well-known routine to determine whether to continue.

Returning to block 3420 of FIG. 7, the computer waits for a new request. The remaining blocks are cycled through '#1 until branching again to block 3390. Subscriber Assuming that you want to retrieve the raw data and perform the analysis on your own computer. , host computer 3 is divided into block 3420 and block 3610 of FIG. branch out

Block 3610 selects the data most appropriate for the information service subscriber's 11 purposes. display various options for employing selected output media. block 36 At 20, computer 3 is given a choice. Block 3630 is "End".

Determine whether or not is selected. If 'End' is selected, block 36 4° returns control to block 3430 of FIG. If “Exit” is not selected, Block 3650 sweeps the data line 6 to Select all data that matches the choices. Block 3660 indicates that the output request is printed. If so, output the data to the printer. request is a hardcopy output, block 3680 indicates that the output request is for magnetic tape. Determine whether or not. If magnetic tape is the requested medium, block 3690 outputs to magnetic tape. If the media request is for diskette, Block 3700 determines this and block 3710 diskens the data. Output to If the output is requested as a display, block 3720 determines this and outputs the data to the requested terminal. block 3740 and 3750 need not be explained.

When the subscriber 11 of the information service finishes acquiring data, the control is terminated by a termination request. Return to FIG. 7. If a further termination request is issued in FIG. 7, control proceeds to FIG. will eventually end.

Interruption of the session with host computer 3 can occur for one of several reasons. It can get stiff. The two reasons why we are able to detect and process on time are the sessions. Occurs when there is no activity on the terminal that started the process. The first is what we are currently doing. Occurs when you are distracted by something and actually leave the device for a certain period of time. . In the second case, the sailing wave signal for communication is interrupted due to trouble in the communication line. It is. In either case, computer 3 detects these conditions and Branches to block 3760. Various condition codes at the time of suspension are shown in block 3760. and stored in a temporary file at block 3770. assist the requester The temporary file created to store the file is also saved at block 3780. Next Bro 3790 terminates the session for the requester.

(The person using the terminal is no longer communicating with the computer) (and the user resumes logging the processing step. At this point, block 420 of FIG. the "yes" branch is taken and control continues to block 3800 of FIG. 9, block 38. At 00, various condition codes are reset to their pre-interrupt state. Pending temporary file All isles are opened at block 3810 and control is suspended via block 3820. With this approach, the request is made by host computer 3. Work performed in support of the request will not be inadvertently lost. return A serasilan that is used produces the same results as if no interruption of service had taken place.

As mentioned above, the office management computer 3 in FIG. Receive not only the diagnosis but also (b) data regarding the treatment administered. It's the doctor's turn To update the necessary information, access the patient's medical record in Figure 21 as described above. have completed the process. This data is used to create a patient emergency abstract. Used to update 1,000 abstracts. The abstract is a summary of the medical treatments the patient has received to date. Record all procedures, including errors and medications administered, and record any % deviations for the patient or physician. Combiator automatically created by the office management computer 3 without any intervention. It is a Phi J-style closing shop.

The first shimeya record can be done directly by interview or 1g! , who provide the necessary information to the doctor. By obtaining information from the patient, indirectly by asking the patient to tell Created by

In the case of a newborn baby, the closing record is completed by the parents using the transaction described in the flowchart above. It is created at the time the work is started for. Medical transaction number, administrative management system The newborn's health records and medical records will be maintained automatically for the entirety of the baby's life. will be updated.

In the case of newborns, identification numbers such as social insurance numbers cannot be used immediately and are not included in the abstract. are assigned a record identifier associated with the cardholder, who is often the parent. w Once an A5311 number (e.g. social security number) is available, newborn A separate file is created for recording.

If the number is incomplete, such as when a person with one color does not tell the first number, the number is This fact will be recorded in the clerk's records.

Doctors and medical records are especially important when it is difficult to share information with the patient, such as when the patient is unconscious. This is particularly useful in case of emergency treatment of a patient, such as in case of emergency. This was mentioned earlier That's right. Furthermore, in connection with first aid treatment, selected The information can be copied to a second emergency abstract by the administrative combiator. Ru. Emergency abstracts can be utilized by health care providers and provide time to read the book in emergency conditions. Contains a select amount of data that may be most important to a limited number of physicians. I'm reading.

There is basic agreement among experts regarding the nature of this data, and - An example list is shown in the questionnaire in Figures 37-39. Rescue 2, the abstract for use is a doctor. Updated with the data contained in the 9 closing rooms and medical records.

What types of data from the closing and medical records should be selected and copied to the emergency abstract? Additional information about Kika can be obtained from the Medical Professional Association, P.O. Box 70, Lake Forest. , IL 60045) and the International Emergency Medicine Foundation (P.O. Box 1009, Turlock). , CA 95380) and from both of the above. r1987 2 9-1, System, which is cited as a reference in the specification. You can purchase a book titled ``Minutes of the Minutes of the Minutes for the People of the Mums''.

Two important features of the closing and medical records are: One of them is that the doctor The data will be updated at the time of notification to the office management computer 3 of 21. . This information includes identification of the diagnosis and treatment performed, and is is input. Changes to records are necessary for proper payment of medical services Physicians can collect patient information in medical records that cannot be derived from inputting diagnostic and treatment codes alone. It should be noted that the addition to the record database is under the doctor's control. sea bream. Physicians cannot change existing information contained in records during the update process. do not have. Of course, if a physician withholds information that properly belongs in a patient's medical record, this may not be recorded. This will affect the integrity of the record. Emergency abstracts are derived under program control It is merely a summary of medical records and medical records, and is independent from doctors.

Second, the abstract does not need to exist as a separate file on your computer. (Also, it probably shouldn't exist as a file to save storage space.) Rather, it is an efficient way to explore medical records and extract selected information. - Chin is available at the time requested by the healthcare provider. Furthermore, this routine The search engine does not need to search a predetermined data list, but can be saved as shown in Figure 4A. Interactive in the sense of being able to respond to specific requests by the physician in the treatment room It can be of type. For example, a doctor might say, ``This patient last received a tetanus shot.'' You can ask a single question, such as "What time did you type?" The computer can It would be possible to search for files of the format shown in 37 and 38 and issue an answer.

In fact, the doctor never actually asks a question, but the 20th line of the file in Figure 37 There may be times when you want to request data for a specified row.

The foregoing description describes the preferred embodiment of the present invention, real-time insurance administration and medical It is a medical utility system. Ideally, the invention would be useful for each medical profession. By providing people with the information they need to make timely and informed decisions. This invention will help meet the demand for comprehensive health management in the community. By having a grasp of important data at the base, data timing, access It solves recurring problems such as incompetence, incompleteness and disappearance. In addition, Real-time databases make data instantly available for use by others.

The value of a real-time database is that people spend money across geographical distances. is realized when many decisions have to be made. receive medical services For people, this means knowing exactly how much a visit to a health care provider will cost. It means that you can. For healthcare providers, when providing services You can know how much benefits will be paid, and in many cases transactional power ( This means that you will actually receive payment at the time the transaction is made.

For health insurance plan sponsors, medical services to eligible employees This means that you will only pay for. In addition, the plan sponsor must Sponsor is subject to collective bargaining agreements and state and federal laws and regulations that impose certain restrictions and obligations. It also means to comply. For medical intermediaries, the average service benefit Financial services that pay for medical services that can be managed by a person It is meant to provide. For information service subscribers, medical and and access to key statistics and raw data for making financial assessments and decisions. It means that

Many substitutions may be made without departing from the true spirit and scope of the invention as claimed. And Shumasa is possible. The scope of the invention is as follows.

FIG-17FIG-21 FIG-24 FIG-37 FIG-38 FIG-39 FIG-40 abstract A service provider terminal (18) having two-way online communication with the central processing unit (3). ), and a real-time system for health administration and medical information, including an updatable central database. time utility. The service provider terminal (18) stores the group member identification data. Cart reader for data entry, group member plan membership qualifications and various proposed options. Queries a central database regarding the cost of prescribed prescriptions by plan. means in the form of a key fob for configuring the Contains a screen for display. A benefit sponsor such as an employer or a group association Central processing unit and two-way online so that members' membership qualifications are updated on-line. A terminal (1,85) for communication is provided.

Heisei Year Month Day

Claims (1)

[Claims] 1. In the real-time utility of health insurance administrative management and medical information, A) a central processing unit maintained by the health insurance plan administrator; and B) 1) a group 2) group member identification data file; and 2) group member beneficiary eligibility status data file. and 3) a group member medical history data file. an updatable central database in communication with the c1) Enter the group membership identification number of the member seeking medical treatment from the service provider. a device to 2) Eligibility for group members to apply for the plan and various options proposed to group members. The amount to be paid under the plan for services and the medical history of group members as described above. 3) a device for calling from a central database; and a device responsively displaying data. a service provider terminal that performs two-way online communication with the central processing unit; ) 1) a device for inputting data on group members' beneficiary eligibility status; and 2) the update device. said central processing unit and a device for displaying data in response to the location of said central processing unit; E) a benefit sponsor terminal that performs online communication with the client; and the paging device, the service provider input device, and the benefits sponsor. in response to the server input device and the database; 1) Create data on the member's beneficiary eligibility status, and 2) Respond to the proposed service. 3) Create a calculated benefit amount corresponding to the treatment administered. 4) Program equipment for creating medical history data files for group members. 2. Utility characterized in that it consists of: the central processing unit; and a transfer device for communicating and transmitting the calculated benefit amount to the service provider. A utility according to claim 1, characterized in that the utility comprises: 3. further comprising a device for printing response data in response to the service provider terminal; The utility according to claim 1, characterized in that: 4. Benefit sponsors now have a program device with an audit system. Claims characterized in that the person has access to statistical data regarding the benefit plan. Utilities described in Section 1. 5. The database also contains brand definition files and the benefit sponsor As set forth in claim 1, the invention is characterized in that it is possible to create and update an application definition file. Utilities. 6. Service provider terminals are equipped with card readers, and group members are provided with services. Sufficient group member identification data to allow the Service Provider to access the Utility. The unit according to claim 1, characterized in that a magnetic card containing the above is attached. -tility. 7. further comprising a subscriber terminal in communication with the central processing unit; a device for calling a central database for each data; and said calling device. and a device for displaying data in response to The utility described in box 1. 8. The service provider terminal further includes an emergency medical inquiry function. Utilities described in item 1 of the scope of the request. 9. An updatable central database further includes group member practice data files. In addition, the service provider terminal also provides information regarding group member medical data and files. A device that calls the central database and updates group member medical data files. a device for inputting data in order to Update the data file with the input treatment data and input medical update data. The utility according to claim 1, characterized in that it is equipped with a device for I. 10. The group membership status data file is updated for members under the second plan. includes information regarding the coverage of the member, and the central processing unit provides information regarding the health insurance plan for the member. Claims characterized by being programmed to coordinate benefits with a second plan Utilities described in scope 1.