Huron Systems - RulePro Technology

RulePro^® Technology

RulePro^® Technology performs four basic functions:

1. Captures

2. Identifies

3. Notifies

4. Confirms

...each encounter's demographic, insurance, and clinical data--as defined by the facility (e.g., payors, planned procedures).

...specific rules that apply to this encounter (e.g., a certification requirement that results from the patient being in a particular Blue Cross group).

...the patient and/or facility personnel of important information related to the rule (e.g., an ABN is printed for a Medicare patient with non-covered services).

...to help assure that tasks related to the matched rules are completed (e.g., the required certification number is obtained and recorded).

These four functions can be applied to multiple healthcare issues/application areas. The major application areas to which RulePro^® Technology has been applied to date are insurance certification and compliance-related activities. However, as noted in the following diagram, RulePro technology can also be applied to a number of other healthcare areas.

1. Insurance Certification

Captures patient's payor, employer, and planned procedure data.

Identifies rules related to the patient's insurance and/or managed care contract requirements.

Notifies Case Management of required rule actions through a printed pre-authorization form.

Confirms that pre-certification number was obtained and entered.

2. Compliance

Captures ancillary service orders, payor, and diagnosis information.

Identifies compliance requirements for non-covered Medicare (and other payor) services.

Notifies patient of financial responsibility by printing ABN form for patient's signature.

Confirms that ABN form was designated as having been signed by patient.

3. Physician Services

Captures patient demographics and planned service data in physician's office.

Identifies rules for coverage as specificied by managed care plan.

Notifies physician office staff of non-covered services via a printed form.

Confirms that patient is aware of non-covered services.

4. Case Management

Captures payor, diagnostic, planned procedure, and physician data.

Identifies protocol requirements that apply to this patient/physician.

Notifies Case Management of the protocol requirements on a customized printed form.

Confirms that required Case Management actions were performed and entered.

5. Co-Payments

Captures patient demographic and payor data in the ER.

Identifies co-payment requirements for patient's managed care plan.

Notifies ER staff of co-payment requirement on customized printed form.

Confirms that co-payment was collected from the patient.

6. Discharge Planning

Captures patient diagnostic, planned procedure, home status, and age data.

Identifies discharge planning needs based upon the patient's characteristics.

Notifies Discharge Planning staff of the patient requirements on customized printed form.

Confirms that Discharge Planning activities were completed.

7. Pre-Encounter Testing

Captures patient diagnostics, planned procedure, and age data.

Identifies pre-encounter testing requirements based upon the patient's characteristics.

Notifies Pre-encounter Testing staff of the patient's test requirements on a customized printed form.

Confirms that required encounter tests were ordered.