...Claims Adjudication Process The claims adjudication process has five steps. The steps are initial processing, automated review, manual review, determination, and payment. In the initial processing paper claims and any paper attachments are stamped with the date and entered into the payer’s computer system, by either data-entry personnel or by scanning them into the system. This process might find problems such as the patient’s name, plan identification number or plan or service code is wrong. The diagnosis code may be incorrect for the date of service or it might be missing altogether, or the gender-specific procedure code is not correct for the patient’s gender. Any claims that have mistakes are rejected. The provider is instructed to correct the errors and re-bill the service. The claim goes through the automated review after the initial process. This review looks at the patient’s time limits for filing claims, referral forms, preauthorization, and the patient’s eligibility benefits. Bundled codes, non-covered services, medical review, concurrent care, utilization review, and duplicate dates of services are also checked for during the automated review. The claim is stopped if problems are found, and the claim is set aside for manual review. During manual review, more information may need to be provided so that the claim process can be finished. An examiner receives the claim, and they can ask the provider for any additional information that is necessary for...
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...the five steps of the claims adjudication process from the time of initial processing through final payment. Include a brief 250- to 300-word explanation for the following: · Identify the purpose for each step in claim adjudication process. · Explain the relationship between each of the different steps. · Provide a one-sentence summary describing how claims adjudication is important to the medical billing process. The claims adjudication process has five steps. These steps are initial process, automated review, manual review, determination, and payment. In the initial process, problems such as the patient’s name, plan of service code, or the plan identification number may be wrong. The diagnosis code may be incorrect for the date of service or might be missing altogether, or it might be that a reported gender-specific code and the patient’s gender do not match up. Any claims that have mistaken are rejected. The provider is instructed by the payer to correct the errors and submit the claim again. The claim goes through the automated review after the initial process. This reviews looks at the patient’s time limits for filing claims, referral forms, preauthorization, and the patient’s eligibility benefits. Bundled codes, non-covered services, medical review, concurrent care, utilization review, and duplicate dates of service are also checked for during the automated review. The claim is stopped if problems are found, and the claim is set aside for...
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...Adjudication Process Tamara Hurley HCR/230 February 19th, 2014 Jill Frawley Adjudication Process There are five steps in the claims adjudication process. Each of these five steps serves the purpose of making sure that a claim is processed properly without any mistakes. Step one is the initial process, in this step most of the simple errors are fixed or caught. Some examples would be the patients name, the diagnose code may not match up with the date of service, or even have the wrong plan identification number. A claim with even one mistake will be rejected, this means that the claim will be sent back to the provider to correct the errors and resubmit the claim. The next step would be the automated review. Here a claim is reviewed for time limits of the claims filed, the benefits that the patient would be eligible for, referral forms, and if they received preauthorization for services. At this stage the claim is also checked for non-covered services, duplicate dates for services, utilization and medical review. If there are problems found in this step than the process on the claim is stopped until it can be reviewed manually. Any information still needed is requested during this review, this will ensure that the claim can be processed. When every mistake or problem has been fixed and handled than the claim will enter the determination process. The determination of if the claim will denied, paid, or have the payment reduced. After all of this than the claim...
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...There are five steps in the claims adjudication process. Initial processing is the first step. Initial processing finds any problems such as; name, identification number, or the plan of service code is wrong. This has to be fixed before anything further can happen. Automated review is a system that checks for ten things that maybe reflected on their payment policy. The review checks for the following; patient’s time limits for filing claims, referral forms, preauthorization, and the patient’s eligibility benefits, bundled codes, non-covered services, medical review, concurrent care, utilization review, and duplicate dates of service. The third step is manual review. Manual review happens if problems occur from the previous review; the claim is suspended and set aside for development. This step is usually followed to review the medical necessity of an unlisted procedure. Determination is the fourth important step. This is where the decision is made to pay it, deny it, or to pay it at a reduced level. If the service falls within normal standings, it will be paid. If it is not reimbursable, the item on the claim is denied. If the examiner determines that the service was at too high a level for the diagnosis, a lower-level code is assigned. The last step is making a payment. If payment is due, the payer sends it to the provider along with a transaction that explains the payment decisions to the provider. Adjudication process is an important process because it checks for any errors...
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...submitting it to a detached third party or bureau for an agreement that could or could not be a binding compare. Adjudication and similar alternatives were essentially set up to give an aerodynamic and cost-conscious option to deal with a legal issue. AAA adjudicators retains dotages of business-definite awareness and maturity. The AAA's board of Adjudicators consist of more than seven thousand persons placed all over the globe. Their oversight is handled by the Association's Code of Ethics for Adjudicators in business conflicts. Facts about AAA adjudicators is feasible to the parties who have already filed a case. The AAA's guidlines and regulations cover adjudication across a wide diversity of businesses and case types. These guidelines and regulations design the steps in the settlement action and makes sure that all parties that are involved in a case are treated fairly and equitably. The Russian structure commendations international alliances to which Russia is a party as an imperative and absolute integral of Russian act. So, international alliance and meeting rules abound in the advent of a rivalry with private Russian act. For consideration to foreign adjudication Russia is also involved in the meeting on the appreciation and administration of Foreign Arbitral Awards of 1958 “New York Convention”, and also to the European meeting on Foreign Business Adjudication of 1961. Russia also belongs to many reciprocal alliances on the bilateral admission and imposition of arbitral...
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...authority. <p>Your browser does not support iframes.</p> This led to a legal struggle between the two parties. The respondents had filed 23 revocation petitions before the Appellate Board, praying for the revocation of the patents held in the name of the appellant. They had also filed counterclaims, in response to the patent infringement suits brought about by the appellants. The litigation had now reached the Supreme Court, in order to determine the correct course of action to be adopted, in the light of compound proceedings having been invoked by the two parties. One of the questions before the court was whether the challenge, having been raised by the defendant through a counter-claim, can only be determined at the hands of the High Court, i.e., while dealing with the counter-claim....
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...I. Synopsis: Case: The HOOVER COMPANY, Plaintiff, v. BISSELL INC., Defendant. No. 5:98-CV-1088. United States District Court, N.D. Ohio, Eastern Division. March 19, 1999. A. The Hoover Company History: Hoover vacuum cleaners have markets in the United States and Canada. In addition to vacuum cleaners, Hoover also produces and sells high quality washers and dryers. Maytag acquired The Hoover Company in 1989, providing Maytag an important foothold in the highly competitive international market. The company roots back to 1827, when Henry Hoover established a plant near Canton, OH. 80 years later led to him and his sons selling vacuum cleaners after purchasing rights to an electric suction sweeper, which was invented a year before by a guy named Murray Spangler. In 1908, Hoover bought Spangler’s patent, kept him as a partner and soon named the company Hoover Suction Sweeper Co. Hoover than began marketing the sweeper in stores all throughout the country. By 1921, Hoover had gone global and by 1923, sales reached $23 million. Hoover today specializes in all floor care and is a continued leader in the industry (Hoover: Fundinguniverse, 2006). B. Bissell Inc. Company History In 1876, Melville Bissell began marketing his carpet sweeper invention with revolving brushes. The revolving brushes picked up the dust and dirt and deposited it inside the sweeper housing. Being dependent on the rotation of the wheels to drive the sweeping mechanism, it only removed debris from...
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...A. Overview of Intellectual Property (Book 24-30) 1. TRADE SECRETS (Outline pgs 3-11) ▪ Trade secret laws are State law doctrines that protect against the misappropriation of certain confidential information. o There is no federal statute ▪ A form of private IP law under which creators establish contractual limitation or build legal fences that afford protection from misappropriation. ELEMENTS: a. The information must be Secret. a. Relative, not absolute, secrecy is required. b. The owner must take Reasonable step to maintain secrecy. a. Once a trade secret is disclosed, protection is lost. c. There is some economic or competitive advantage to the owner. i. Misappropriation of Trade Secret: 1) Where the secrets were obtained by theft or other improper means. 2) Where they were used or disclosed by the D in violation of a confidential relationship. ▪ Trade secret does not prevent competitors from “reverse engineering” which is permitted. 2. PATENTS (Outline pgs 12- 31) a. 5 Requirements: 1) patentable subject matter (g.15) 2) utility (pg.16) 3) Description & Enablement (pg.17) 4) novelty & Statutory bar (pg.19) 5) non-obviousness...
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...In this case we will be talking about the company RIM (Research in Motion) and some of the Challenges they faced to protect their Intellectual Property. Research in Motion is best known as the developer of the Blackberry smartphone. Research in Motion was involved on several Patent Litigation with the different competitors. On 1999 Glenayre Technologies (formerly known as Glenayre Electonics) filed a patent infringement suit against RIM claiming that the Inter@ctive pager line used Glenayre’s power-generation from dual battery process. This litigation caused a delay on RIM’s contract renewal with the BellSouth company and also their quarterly earnings report came with lower than expected results. In order to get new customers RIM signed an agreement with Dell Computer and Dell started selling Blackberry to large corporate accounts. On 2001 RIM replied back to Glenayre filing a suit against them for infringing on RIM’s “Single Mailbox Integration” patent. Research in Motion won this patent and allowed them to collect royalties from other mobile device makers that were planning on utilizing this technology. On 2002 Research in Motion filed the first of four suits against Good Technology for misappropriation of trade secrets, this dispute continued until 2004 where they settled an agreement. Good Technology agreed to pay a sum of money and quarterly licensing fees. Another legal dispute was the patent for the keyboard design against Handspring for its Treo device but...
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...August 2011 I realized recently that we may be able to solve part of the patent problem without waiting for the government. I've never been 100% sure whether patents help or hinder technological progress. When I was a kid I thought they helped. I thought they protected inventors from having their ideas stolen by big companies. Maybe that was truer in the past, when more things were physical. But regardless of whether patents are in general a good thing, there do seem to be bad ways of using them. And since bad uses of patents seem to be increasing, there is an increasing call for patent reform. The problem with patent reform is that it has to go through the government. That tends to be slow. But recently I realized we can also attack the problem downstream. As well as pinching off the stream of patents at the point where they're issued, we may in some cases be able to pinch it off at the point where they're used. One way of using patents that clearly does not encourage innovation is when established companies with bad products use patents to suppress small competitors with good products. This is the type of abuse we may be able to decrease without having to go through the government. The way to do it is to get the companies that are above pulling this sort of trick to pledge publicly not to. Then the ones that won't make such a pledge will be very conspicuous. Potential employees won't want to work for them. And investors, too, will be able to see that they're the...
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...ALL ABOUT PATENTS IN BOTSWANA Procedures for filing patent applications in Botswana Filing requirements for national phase PCT applications are as follows: * Power of attorney (simply signed; can be late-filed within one month) * Copy of published international application (required on the day of filing) * Specification, claims and abstract in English, if publication not in English (required on the day of filing) * Copy of international search report (can be late-filed, no set deadline) Filing requirements for invention patents are: * Power of attorney (simply signed; can be late-filed, within one month) * Specification, claims and abstract in English (required on the day of filing) * Formal drawings, if applicable (required on the day of filing) * Assignment of invention (can be late-filed, no set deadlines) How long will it take to register a patent and what are the standard costs? Approximately three years from filing. The official fee for filing a Botswana patent application is P300 (approximately $40) and the official fee for grant and publication is an additional P300. What is the scope of patent protection in your jurisdiction? A Botswana patent for a product confers upon the patentee the right to preclude any other person from making, importing, selling, using the product, or offering it for sale. What types of inventions or ideas can be patented? Are there any notable or unusual exceptions? An invention is...
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...Ttools case study The goal of this analysis is to understand the opportunity and challenges ttools faces and advise them on the best approach to go forward. Ttools has created a unique all –in-one stylus for PDAs which also functions as regular ink pen. They have a successful utility patent and are facing a few challenges in patent infringement, marketing & distribution. Ttools has to decide whether they should compete, negotiate or litigate against Palm/IDEO for their product. To choose the best option going forward, we will look at the each of the options in depth and analyse the potential impact on the outcome. Competing against Palm Currently ttools uses Palm’s distribution channels (InSync online) to target potential customers. Competing against them would require ttools to aggressively spend resources on marketing and distribution channels that currently don’t exist. As the case mentions, the total cost of manufacturing a single unit costs approximately $2 with a mark-up of $9.95, the extra resources would drive the profit margins much lower. With a lower profit margin and lack of resources to scale the market, Palm would certainly out size ttools in pricing and marketing/distribution with an abundance of resources and large market share. Negotiate with Palm To continue using Palm as their primary distribution platform, ttools would effectively nullify their patent to reach an agreement. InSync platform reaches 50,000 of Palm’s customers, total potential revenue for...
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...Patent Warfare Per your request I reviewed the lawsuit notice and believe our company can handle the matter without litigation saving us time and money. Our first course of action should be to propose collaboration with the accuser in order to continue innovation. If the accuser turns out to be a patent troll or in other terms in the business of strictly making money on infringement cases we will have the case arbitrated by a subject matter expert. I recommend we offer the accuser a chance to collaborate with a business which recently launched a great new product supported by Apple iOS and Google Android platforms. Instead of being a killer of creativity the accuser might be a legitimate technology developer such as our company. The accuser may be more interested in developing newer and better versions of its product instead of getting a onetime payout. Collaboration will save both parties time and money by avoiding a long and expensive court case. It will also benefit both parties to share research and new ideas (Laudon, 2012). Nokia and HTC are a recent example of collaborations as they entered “into a collaboration agreement to provide access to each other’s patented technology to explore future projects” (Shankar, 2014). Working together will provide our business with new innovations making us more competitive. New innovations will develop an opportunity for new registered patents to our company, providing a defense system for possible future law suits. Licensing...
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...realized recently that we may be able to solve part of the patent problem without waiting for the government. I've never been 100% sure whether patents help or hinder technological progress. When I was a kid I thought they helped. I thought they protected inventors from having their ideas stolen by big companies. Maybe that was truer in the past, when more things were physical. But regardless of whether patents are in general a good thing, there do seem to be bad ways of using them. And since bad uses of patents seem to be increasing, there is an increasing call for patent reform. The problem with patent reform is that it has to go through the government. That tends to be slow. But recently I realized we can also attack the problem downstream. As well as pinching off the stream of patents at the point where they're issued, we may in some cases be able to pinch it off at the point where they're used. One way of using patents that clearly does not encourage innovation is when established companies with bad products use patents to suppress small competitors with good products. This is the type of abuse we may be able to decrease without having to go through the government. The way to do it is to get the companies that are above pulling this sort of trick to pledge publicly not to. Then the ones that won't make such a pledge will be very conspicuous. Potential employees won't want to work for them. And investors, too, will be able to see that they're the sort of company...
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...Running Head: MIRROR WORLDS VERSUS APPLE, INC. 1 Mirror Worlds versus Apple, Inc. Willful Infringement MIRROR WORLDS VERSUS APPLE, INC. 2 ABSTRACT This paper will discuss the lawsuit filed by Mirror Worlds LLC against Apple, Inc. for infringement of four patents owned by Mirror Worlds. Mirror Worlds’ patents cover intellectual property; namely that of digital and visual media and the consolidation and sorting thereof. The jury’s verdict in this case awarded Mirror Worlds a substantial amount of money for damages caused by the supposed willful infringement of Apple, Inc. In addition, Apple, Inc.’s arguments, namely involving the claim of willful infringement, evolving into a counterclaim against Mirror Worlds will also be discussed. Keywords: intellectual property, patents, infringement, software, documents, counterclaim, willful infringement MIRROR WORLDS VERSUS APPLE, INC. 3 Mirror Worlds versus Apple, Inc. Willful Infringement In February of 2010, the United States Patent and Trademark Office, USPTO, granted Apple Inc. a design patent on Cover Flow, which covers the design and display of specific documents, but not the functionality. “A patent is a legal right, for a limited term, to exclude others from using, selling or making an invention or discovery.” (Kay, Millonzi and Passannante, 2001). Patent D609715 regards an “animated graphical user interface for a display screen or portion thereof. The process or period in which an image transitions to...
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