US-20260127681-A1 - INSURANCE CLAIM DENIAL MANAGEMENT SYSTEM USING INTEGRATED PROGRAMMATIC AND SPECIALIZED GUIDED AND CONSTRAINED ARTIFICIAL INTELLIGENCE

US20260127681A1US 20260127681 A1US20260127681 A1US 20260127681A1US-20260127681-A1

Abstract

An automatic insurance claim denial management system and process are disclosed. The automatic insurance claim denial management method receives a notification of denial of the insurance claim by one or more payers. The notification also includes an Electronic Remittance Advice (ERA) reconciliation data provided by the payer. One or more reasons for claim denial are automatically identified by analyzing the ERA data. After analysis of the ERA data and knowing one or more reasons for the denial of the insurance claim, corrections are applied to an insurance claim form i.e., rejected by the payer. Finally, the modified insurance claim form is submitted to the payer, ensuring that the insurance claims meet the necessary criteria for approval upon re-submission.

Inventors

Anusha Tiwari
Animesh Kumar

Assignees

Ocean Friends, Inc.

Dates

Publication Date: 20260507
Application Date: 20251105

Claims (13)

1 . A method of automatically managing denied insurance claims from at least one payers, the method comprises: executing code using at least one processors of a computer system to cause the computer system to perform operations comprising: receiving a notification of denial of an insurance claim by the payer responsive to a previously submitted insurance claim form, wherein the notification includes an Electronic Remittance Advice (ERA) reconciliation data provided by the payer; automatically analyzing the ERA data to identify at least one reason for denial of the insurance claim, wherein automatically analyzing the ERA data comprises: accessing the ERA data from a memory; accessing insurance claim denial codes in a repository of denial codes; and mapping the identified denial reason to a corresponding denial code by matching the denial reason to the corresponding denial code; prompting an artificial intelligence engine to determine an insurance claim correction recommendation, wherein the prompt is guided with denial code data and historical successful rejected claim submission data; automatically applying corrections to the previously submitted insurance claim form based on the identified at least one denial reason; and automatically re-submitting the corrected insurance claim form to the payer for approval by the payer.
2 . The method of claim 1 wherein the at least one reasons for denial of the insurance claim includes inaccurate information, insurance expiration, the amount exceeding the threshold values, non-covered medical sessions, general errors, and incomplete information from users.
3 . The method of claim 1 wherein the ERAs provide detailed information about the payment, including an amount paid, any adjustments made, and the reason codes.
4 . The method of claim 1 wherein identifying a payment status from the reasons of the denied insurance claims further comprises: not paid due to inaccurate information, insurance expiration, the amount exceeding the threshold values, non-covered medical sessions, general errors, and incomplete information from users; and partially paid insurance claims due to non-covered medical sessions, and the amount exceeding the threshold values.
5 . The method of claim 1 wherein the modified claim form acts as a secondary medical insurance claim sent to the payer.
6 . The method of claim 1 , wherein the errors and discrepancies that cause the insurance claim to be rejected and require modifications are automatically detected and flagged based on the analyzed ERA reconciliation data.
7 . The method of claim 1 wherein the modifications needed for fixing the denied or rejected insurance claims include: adding or updating documentation that supports the pending insurance claim, such as medical records, patient information, and treatment details; filling in any missing or incomplete information blocks that are required for accurate insurance claim processing, such as personal details, patient identification, and insurance details; and correcting any errors and omissions found in the original insurance claim submission, such as incorrect patient data.
8 . The method of claim 1 wherein the payer is an insurance company, provided with a unique ID code.
9 . A system for automatically managing denied insurance claims from one or more payers comprises: one or more processors of a computer system; and a memory, coupled to the one or more processors, that stores code and execution of the code by the one or more processors causes the computer system to perform operations comprising: receiving a notification of denial of an insurance claim by the payer responsive to a previously submitted insurance claim form, wherein the notification includes an Electronic Remittance Advice (ERA) reconciliation data provided by the payer; automatically analyzing the ERA data to identify at least one reason for denial of the insurance claim, wherein automatically analyzing the ERA data comprises: accessing the ERA data from a memory; accessing insurance claim denial codes in a repository of denial codes; and mapping the identified denial reason to a corresponding denial code by matching the denial reason to the corresponding denial code; prompting an artificial intelligence engine to determine an insurance claim correction recommendation, wherein the prompt is guided with denial code data and historical successful rejected claim submission data; automatically applying corrections to the previously submitted insurance claim form based on the identified at least one denial reason; and automatically re-submitting the corrected insurance claim form to the payer for approval by the payer.
10 . The system of claim 10 wherein the denied insurance claims are visible to the user or healthcare provider on a user interface integrated within the online billing platform.
11 . The system of claim 10 wherein the one or more databases store historical claim data, patient records, and documentation necessary for verifying and supporting insurance claims when denied or rejected by the payer.
12 . The system of claim 10 wherein the analyzer utilizes machine learning algorithms to identify patterns in the denial reasons to predict potential issues in future insurance claim submissions for each user.
13 . The system of claim 10 wherein the notification module notifies healthcare providers and users about the presence of the denied or rejected insurance claims, including notifications for insurance claims requiring immediate attention or additional documentation.

Description

CROSS-REFERENCE TO RELATED APPLICATION(S) This application claims the benefit under 35 U.S.C. § 119(e) and 37 C.F.R. § 1.78 of U.S. Provisional Application No. 63/716,725 which is incorporated by reference in its entirety. FIELD OF THE INVENTION The present invention generally relates to the field of electronics, and more specifically to a system of handling or management of denied medical insurance claims from the insurance company due to a plurality of reasons. BACKGROUND OF THE INVENTION In healthcare, managing health insurance claim denials is a critical process because it directly impacts a provider's revenue. A claim denial occurs when an insurance company, government payer, or another third-party payer refuses to pay for medical services that a healthcare provider has already delivered. This rejection can happen for a variety of reasons, including mistakes in medical billing, incorrect or incomplete patient information, coding errors, or services deemed medically unnecessary by the insurance company. When a claim is denied, it causes a delay in payment, which can disrupt the provider's cash flow. If the denial is not resolved, it can lead to a permanent loss of revenue. For hospitals, diagnostic centers, and clinics that depend on regular income to cover operating costs like staff salaries, medical supplies, and other expenses, claim denials can create significant financial strain. This makes timely denial management essential to maintain the financial health of the organization. Effective denial management involves identifying the reasons for denials, correcting any errors, resubmitting claims, and ensuring that future claims are submitted accurately to avoid repeat denials. It also requires careful attention to detail in medical coding, which translates the services provided into standardized codes used by insurers to determine payments. Any inaccuracies in this process can lead to claims being denied, making it crucial for healthcare providers to invest in proper training and technology to restructure their billing processes. SUMMARY An automatic insurance claim denial management system and process are disclosed herein which deals with the management of the denied or rejected insurance claims by the payer due to a plurality of reasons. The reason for the insurance claim denial can be identified automatically using the insurance claim denial management system, based on which the modifications can be made automatically. In an embodiment of the present disclosure, an automatic insurance claim denial management process is disclosed. The automatic insurance claim denial management method receives a notification of a denial (also referred to herein as a rejection) of the insurance claim by one or more payers. The notification also includes an Electronic Remittance Advice (ERA) reconciliation data provided by the payer. The one or more reasons due to which the claims are denied or rejected by the payer are automatically identified by analyzing the ERA data. After the analysis of the ERA data and knowing one or more reasons for the rejection or denial of the insurance claim, a set of corrections are applied to an insurance claim form i.e., rejected by the payer. The set of corrections can be done both manually, as well as automatically. Finally, the modified insurance claim form is submitted to the payer, ensuring that the insurance claims meet the necessary criteria for approval upon re-submission. The modified insurance claim form is known as a secondary insurance claim form. In addition, an automatic insurance claim denial management system is disclosed. The automatic insurance claim denial management system for managing the denial or rejected insurance claims by the payer includes a computer system with one or more processors and databases, operatively coupled to the processors, to perform specific operations. The automatic insurance claim denial management system receives a notification of rejection or denial of the insurance claim by one or more payers via. a notification module. The notification also includes an Electronic Remittance Advice (ERA) reconciliation data provided by the payer. The notification is displayed to the user on a user interface, which is integrated within an online billing platform. The one or more reasons due to which the claims are denied or rejected by the payer are automatically identified by analyzing the ERA data using an analyzer. After the analysis of the ERA data by the analyzer and knowing one or more reasons for the rejection or denial of the insurance claim, corrections are applied to an insurance claim form i.e., rejected by the payer automatically using an insurance claim modifier. The corrections can be done both manually, as well as automatically. Finally, an uploader submits the modified insurance claim form to the payer, ensuring that the insurance claims meet the necessary criteria for approval upon re-submission. The modified insurance claim form is known a