Patent ID: 7363240

Claim:
A computer implemented and user assisted method for providing medical referrals and medical assignments to medical insurance claims, comprising: receiving by a claim handler a reported medical insurance claim and collecting by the claim handler data related to the reported medical insurance claim; forwarding the reported medical insurance claim and the collected data relating to the reported claim to medical referral logic; automatically performing the medical referral logic on the reported medical insurance claim and the collected data to determine whether a medical referral is warranted based upon predetermined referral criteria; when the medical referral is warranted, automatically forwarding the reported medical insurance claim and the collected data to a medical case management system for review by a medical case manager; when the medical referral is not warranted, preventing the reported medical insurance claim and the collected data from being referred to the medical case management system; when the medical referral is warranted and the reported medical insurance claim is reviewed by the medical case manager, assigning the reported medical insurance claim by the medical case manager to a medical personnel when the assignment is warranted based upon predetermined assignment criteria; collecting updated data relating to the reported medical insurance claim when the data changes and when the updated data is present; performing the medical referral logic on the reported medical insurance claim and the updated collected data to determine whether a medical referral is warranted based upon the predetermined referral criteria; and when the medical referral is warranted, automatically forwarding the reported medical insurance claim and the updated collected data to a medical case management system for review by a medical case manager to determine whether to assign the reported medical insurance claim to the medical personnel.