Rules engine framework

This application claims priority to U.S. Provisional Application Ser. No. 61/048,810 filed Apr. 29, 2008, and entitled “MMIS Health Enterprise Solution,” by Jack Devos, et al., which is incorporated herein by reference for all purposes.

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The United States Medicaid program was enacted in 1965 to provide a medical assistance program for individuals and families with low incomes. The Medicaid program comprises three main entities—the patients, the healthcare providers, and the agency administering the plan (i.e., the payer). The Medicaid program is financed through joint federal and state funding. The Medicaid program is administered by each state according to an approved state plan. The specifics of the Medicaid program differ from state to state. Differences may include covered healthcare procedures, allowable procedure costs, and patient eligibility criteria. The state administrators of the Medicaid program are required to have a Medicaid management information system (MMIS) that provides for mechanized and/or computerized Medicaid claims processing. Recently, the Medicaid information technology architecture (MITA) has been promulgated by the U.S. government to provide a blueprint and a set of standards that individual states are to follow in administering the Medicaid program and for developing the next generation MMIS.

In an embodiment, an apparatus is disclosed. The apparatus comprises a computer system and an integrated development environment application. When executed on the computer system, the integrated development environment application promotes defining a plurality of rules based on a plurality of generic templates and automatically incorporating input value validation based on a type of a left hand variable into the rules. The rules, when executed by a healthcare management information system rules engine, promote enrollment of health care providers and healthcare system members and processing of healthcare claims.

In another embodiment, a method of processing a healthcare claim is disclosed. The method comprises composing a rule from at least one of a generic template, system parameters custom template, a system list custom template, and a valid values custom template. The method also comprises invoking a business process function to process a healthcare claim and the business process invoking the rule to be processed by a rules engine. The method also comprises the rules engine returning the result of processing the rule in a rule return object and the business process approving payment the healthcare claim based on the rule return object.

In another embodiment, a system is disclosed. The system comprises a computer system and a rules engine framework. When executed on the computer system, the rules engine framework promotes composing a plurality of rules. Each rule is composed at least in part from a left hand variable associated with a right hand input by an operator. The rules engine builder also automatically incorporates into the rules input value validation of the right hand input operand based on the type of the left hand variable. At least some of the rules are composed based on at least one of a generic template, system list custom template, a system parameters custom template, and a valid values custom template. The rules engine builder also builds a healthcare management information system rules engine based at least in part on a plurality of custom providers. The healthcare management information system rules engine promotes enrollment of health care providers and patients and promotes healthcare claims processing.

These and other features will be more clearly understood from the following detailed description taken in conjunction with the accompanying drawings and claims.

BRIEF DESCRIPTION OF THE DRAWINGS

For a more complete understanding of the present disclosure, reference is now made to the following brief description, taken in connection with the accompanying drawings and detailed description, wherein like reference numerals represent like parts.

FIG. 1 is a schematic diagram of a rules engine framework according to an embodiment of the disclosure.

FIG. 2 is a flowchart of a method according to an embodiment of the disclosure.

FIG. 3 is a schematic diagram of an exemplary general-purpose computer system suitable for implementing the several embodiments of the disclosure.

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