Patent ID: 7979289

Claim:
In a computerized medical care system, a method for providing pre-approval for medical services and charges associated with the medical services, the method comprising: receiving by a server computer from a requesting device, a medical claim including a service code associated with a proposed medical service for a diagnosed condition for a patient prior to rendering the medical service by a medical provider, and a proposed charge for the medical service; identifying by the server computer one or more filters enabled for the computerized medical care system; applying by the server computer the identified one or more filters for the received medical claim, the identified filters accessing a historical database of patient records with historical data on medical procedures rendered to at least a plurality of other patients for the diagnosed condition, wherein the historical data includes data of past charges for the proposed medical service; determining by the server computer whether the proposed medical service is medically necessary for the diagnosed condition and whether the proposed charge is reasonable or unreasonable, based on at least the historical data, wherein the determining whether the proposed charge is reasonable or unreasonable includes comparing the proposed charge to a threshold value selected based on the historical data of past charges for the proposed medical service for determining that the proposed charge is presumptively unreasonable if the charge is above the threshold value, but reasonable if the proposed charge is at or below the threshold value; providing by the server computer based on the determination, feedback to the requesting device on whether the proposed medical service is medically necessary and reasonably charged prior to the rendering of the medical service by the medical provider, wherein if the proposed medical service is determined to be medically necessary and reasonably charged, the feedback includes pre-approval for the received medical claim for ensuring payment to the medical provider according to the proposed charge; and if the proposed medical service is determined to be medically unnecessary based on at least the historical data, prompting the medical provider by the server computer to submit information justifying the proposed service for reevaluating the proposed medical service; and if the proposed charge is determined to be unreasonable based on at least the historical data, determining by the server computer a reasonable amount that will be paid to the medical provider and informing the medical provider of the determined amount, the server computer further prompting the medical provider to submit information justifying the proposed charge for reevaluating the proposed charge.