DETAILED ACTION
1. The present application, filed on or after March 16, 2013, is being examined under the first inventor to file provisions of the AIA . This Office action is in response to Applicant’s communication filed on February 20, 2026. Amendments to claims 1, 11 and 15 have been entered. Claims 1-18 are pending and have been examined. The statement of reasons for the indication of allowable subject matter (over prior art) was already discussed in the Office action mailed on November 5, 2024 and hence not repeated here. The rejections and response to arguments are stated below.
Claim Rejections - 35 USC § 101
2. 35 U.S.C. 101 reads as follows:
Whoever invents or discovers any new and useful process, machine, manufacture, or composition of matter, or any new and useful improvement thereof, may obtain a patent therefor, subject to the conditions and requirements of this title.
3. Claims 1-18 are rejected under 35 U.S.C. § 101 because the claimed invention is directed to an abstract idea without significantly more.
The claim(s) recite(s) a system for providing a platform for automating healthcare insurance administration, which is considered a judicial exception because it falls under the category of “Certain Methods of organizing human activity” such as fundamental economic practice as well as commercial or legal interactions including agreements as discussed below. This judicial exception is not integrated into a practical application as discussed below. The claim(s) does/do not include additional elements that are sufficient to amount to significantly more than the judicial exception as discussed below.
Analysis
Step 1: In the instant case, exemplary claim 1 is directed to a system (apparatus).
Step 2A – Prong One: The limitations of “A system for providing a platform for automating healthcare insurance administration, the system comprising:
at least one user computing device in operable connection with a user network; and
an application server in operable communication with the user network, the application server configured to host an application system for providing a platform for automating healthcare insurance administration, the application system comprising:
a core enterprise system configured to execute rule-based data transformations and interoperability between provider contracts, provider recruitment, membership onboarding, member benefit entitlements, and clinical encounter submissions, wherein the core enterprise system comprises a centralized core data management framework serviced by an intelligent data manager that integrates processes between providers and contract agreements, members and their benefit entitlements, and clinical encounter submissions into a unified multi-domain master data management (MDM) architecture providing centralized interoperability between member MDM, health plan MDM, contract MDM, provider MDM, encounter MDM, and claims MDM data domains; ;
an encounters module configured to automatically sort and triage care delivery points of service for individual case management, enterprise utilization management, charge code payments, and pre-claims data processing, wherein the encounters module receives encounter data in a combination of structured and unstructured data input formats and transforms the encounter data into a structured data format defined by the platform framework suitable for payor operations;
a claims module configured to automatically pay and reconcile provider and member reimbursements for a paid claim using industry charge codes and electronic data interchange (EDI) transactions; and
an intelligent data manager configured to process structured and unstructured healthcare data to generate audit-ready care delivery utilization, traceability, and regulatory-compliant reporting;
wherein the application system is further configured to automatically process and validate the fees for provider-to-contract assignments, payment for member-to-benefits entitlement, encounter-to-claims pre-processing and management, and care delivery for individual case management and enterprise utilization tracking via a by applying artificial intelligence and machine learning methods to a set of centralized data repository repositories comprising structured and unstructured data;
wherein the application system further comprises a user interface for providing access to the application system through the at least one user computing device, where the user interface is configured to present member enrollment, member eligibility based on insurance plan entitlements, provider fee schedules, timely access to care, provider network adequacy, care authorizations, encounters between providers and patients, compliance alerts, fraud-detection notifications, overpayment recoveries, and provider reimbursement status visualizations to authorized users in real-time, thereby providing a technological improvement over error prone manual healthcare payor administration” as drafted, when considered collectively as an ordered combination without the italicized portions, is a process that, under the broadest reasonable interpretation, covers the category of “Certain Methods of organizing human activity” such as fundamental economic practice as well as commercial or legal interactions including agreements.
Automating healthcare insurance administration is a fundamental economic practice such as insurance.
The steps of “an application server in operable communication with the user network, the application server configured to host an application system for providing a platform for automating healthcare insurance administration, the application system comprising: ……
an intelligent data manager configured to process structured and unstructured healthcare data to generate audit-ready care delivery utilization, traceability, and regulatory-compliant reporting;
wherein the application system is further configured to automatically process and validate the fees for provider-to-contract assignments, payment for member-to-benefits entitlement, encounter-to-claims pre-processing and management, and care delivery for individual case management and enterprise utilization tracking via a by applying artificial intelligence and machine learning methods to a set of centralized data repository repositories comprising structured and unstructured data;
wherein the application system further comprises a user interface for providing access to the application system through the at least one user computing device, where the user interface is configured to present member enrollment, member eligibility based on insurance plan entitlements, provider fee schedules, timely access to care, provider network adequacy, care authorizations, encounters between providers and patients, compliance alerts, fraud-detection notifications, overpayment recoveries, and provider reimbursement status visualizations to authorized users in real-time” considered collectively, without the italicized portions, is fulfilling agreements in the form of insurance contracts. Hence, the steps of the claim, considered collectively as an ordered combination without the italicized portions, covers the abstract category of “Certain Methods of organizing human activity”.
That is, other than, at least one user computing device, a user network, an application server in operable communication with the user network, a platform for automating healthcare insurance administration, the application system including a core enterprise system, an encounters module, a claims module, an intelligent data manager, artificial intelligence and machine learning, a centralized data repository comprising structured and unstructured data, an intelligent data manager, the MDMs and a user interface of the application system for providing access to the application system, nothing in the claim precludes the steps from being performed as a method of organizing human activity. If the claim limitations, under the broadest reasonable interpretation, covers methods of organizing human activity but for the recitation of generic computer components, then it falls within the “Certain methods of organizing human activity” grouping of abstract ideas. Accordingly, the claim recites an abstract idea.
Step 2A – Prong Two: The judicial exception is not integrated into a practical application. In particular, the claim only recites the additional elements of at least one user computing device, a user network, an application server in operable communication with the user network, a platform for automating healthcare insurance administration, the application system including a core enterprise system, an encounters module, a claims module, an intelligent data manager, artificial intelligence and machine learning, a centralized data repository comprising structured and unstructured data, an intelligent data manager, the MDMs and a user interface of the application system for providing access to the application system to perform all the steps. A plain reading of at least Figures 1-2I and descriptions in at least paragraphs [0005] – [0030] reveals that the at least one user computing device may be a generic user device like a laptop, a mobile telephone etc. The user network may be any generic wired or wireless network. The application server (including a core enterprise system) with a platform and a user interface may be a generic server suitably programmed to execute the claimed steps. The core enterprise system, an encounters module, a claims module, an intelligent data manager, the MDMs, artificial intelligence and machine learning are all broadly interpreted to include generic software suitably programmed to perform the associated functions. The centralized data repository comprising structured and unstructured data is broadly interpreted to include generic databases suitably programmed to store the respective data. The user interface of the application system for providing access to the application system is broadly interpreted to include generic software suitably programmed to perform the associated functions. Hence, the additional elements in the claims are all generic components suitably programmed to perform their respective functions. The additional elements in all the steps are recited at a high-level of generality (i.e., as generic computer components performing generic computer functions) such that it amounts no more than mere instructions to apply the exception using generic computer components. Accordingly, these additional elements do not integrate the abstract idea into a practical application because they do not impose any meaningful limits on practicing the abstract idea. Hence, claim 1 is directed to an abstract idea.
Step 2B: The claim does not include additional elements that are sufficient to amount to significantly more than the judicial exception. As discussed above with respect to integration of the abstract idea into a practical application, using the additional elements (identified above) to perform the claimed steps amounts to no more than mere instructions to apply the exception using a generic computer component. The additional elements of the instant underlying process, when taken in combination, together do not offer substantially more than the sum of the functions of the elements when each is taken alone. Mere instructions to apply an exception using a generic computer component cannot provide an inventive concept. Hence, independent claim 1 is not patent eligible. Independent claims 11 and 15 are also not patent eligible based on similar reasoning and rationale.
Dependent claims 2-10, 12-14 and 16-18, when analyzed as a whole are held to be patent ineligible under 35 U.S.C. 101 because the additional recited limitations only define the abstract idea further.
For instance, in claims 2, 12 and 16, the steps “providing a platform for automating healthcare insurance operational administration, wherein the application server is configured to host an application system for providing a platform that automates a payor’s transition from a fee-for-service to a value-based care while complying with regulatory changes affecting payor operations” under the broadest reasonable interpretation, are further refinements of methods of organizing human activity because these steps describe the intermediate steps of the underlying process.
In claims 3, 13 and 17, the steps “further comprising: a set of database structures for storing healthcare insurance information associated with at least one user, including at least one of claims, payor policies, or payment information, wherein the database is accessible by authorized healthcare providers and insurance companies for processing member claims and provider payments” under the broadest reasonable interpretation, are further refinements of methods of organizing human activity because these steps describe the intermediate steps of the underlying process. The additional element, in the claims, of set of database structures for storing healthcare insurance information associated with at least one user is broadly interpreted to include a generic database suitably programmed to store the associated data/information. The additional element of the database for storing healthcare insurance information, performs a traditional function recited at a high-level of generality such that it amounts no more than mere instructions to apply the exception using generic computer components.
In claims 4, 14 and 18 the steps “comprising: a core enterprise system in operable communication with a user network, where the core enterprise system is configured to provide at least one of a multi-domain structured data for member MDM, health plan MDM, contract MDM, provider MDM, encounter MDM, claims MDM, or business rule handling” under the broadest reasonable interpretation, are further refinements of methods of organizing human activity because these steps describe the intermediate steps of the underlying process. The additional elements, in the claims, of the MDMs and business rule handling are broadly interpreted to include a generic software suitably programmed to perform the associated functions. The additional elements of the MDMs and business rule handling, perform their traditional function recited at a high-level of generality such that it amounts no more than mere instructions to apply the exception using generic computer components.
In claims 5-10, the steps “comprising:
“a claims module configured to provide for paying and reconciling a provider and at least one member reimbursement for a paid claim”,
“a provider module configured to provide at least one of provider contracts management, provider network agreement management, provider fee schedule, capitation payments, provider data CRM workflow, provider credentialing CRM support, embedded or internal data capture, or facilities sites review”,
“a contract management module configured to provide at least one of provider fee scheduling and contract management for physicians, nurses, surgical technicians, or ancillary providers”,
“a plan benefit administration module configured to provide member entitlement for at least one of plan insurance products, benefit management, plan reference code management, line of business plan management, or plan rate association development”,
“a member module configured to provide at least one of member plan entitlement, support, eligibility, enrollment, provider assignment, call center workflow control for member support, customer relationship management, or workforce payor operations management” and
“an encounter module configured to provide at least one of EDI processing, provider processing, or encounter processing, triage care delivery authorized claims for service payments, and triage care delivery pre-authorized claims for service payments”
under the broadest reasonable interpretation, are further refinements of methods of organizing human activity because these steps describe the intermediate steps of the underlying process. The additional elements of the claims module, the provider module, the contract management module, the plan benefit administration module, the member module and the encounter module are broadly interpreted to correspond to generic software suitably programmed to perform the associated functions. The additional elements of these modules, perform their traditional functions recited at a high-level of generality such that it amounts no more than mere instructions to apply the exception using generic computer components.
In all the dependent claims, the judicial exception is not integrated into a practical application because the limitations are recited at a high-level of generality such that it amounts no more than mere instructions to apply the exception using generic computer components. Also, the claims do not affect an improvement to another technology or technical field; the claims do not amount to an improvement to the functioning of a computer system itself; the claims do not affect a transformation or reduction of a particular article to a different state or thing; and the claims do not move beyond a general link of the use of an abstract idea to a particular technological environment. In addition, the dependent claims do not include additional elements that are sufficient to amount to significantly more than the judicial exception. The additional elements of the instant underlying process, when taken in combination, together do not offer substantially more than the sum of the functions of the elements when each is taken alone. The claims as a whole, do not amount to significantly more than the abstract idea itself. For these reasons, the dependent claims also are not patent eligible.
Response to Arguments
4. In response to Applicants arguments on pages 9-14 of the Applicant’s remarks that the claims are patent-eligible under 35 USC 101 when considered under MPEP 2106, the Examiner respectfully disagrees.
The fact that the claims are Patent-Ineligible when considered under the MPEP 2106 has already been addressed in the rejection and hence not all the details of the rejection are repeated here.
Response to Applicants’ arguments regarding Step 2A – Prong one:
The claims recite a system and method for providing a platform for automating healthcare insurance administration, which is considered a judicial exception because it falls under the category of “Certain Methods of organizing human activity” such as fundamental economic practice as well as commercial or legal interactions including agreements as discussed in the rejection. Automating healthcare insurance administration is a fundamental economic practice such as insurance. Also, as discussed in the rejection, the other claimed steps considered collectively, without the italicized portions, is fulfilling agreements in the form of insurance contracts. Hence, the claims recite an abstract idea. The Examiner has considered all the steps in arriving at the overall abstract idea (embodied by the claims)” of a system and method for providing a platform for automating healthcare insurance administration. Abstract ideas can be characterized at different levels of abstraction. (See Apple, Inc. v. Ameranth, Inc., 842 F.3d 1229, 1240-41 (Fed. Cir. 2016) (“An abstract idea can generally be described at different levels of abstraction.”)). As discussed in the rejection, the additional elements (identified in the rejection) are used as tools in their ordinary capacity to apply the abstract idea.
The claimed features and those mentioned on pages 10-11 of the remarks such as “a centralized core data management framework serviced by an intelligent data manager that integrates processes between providers and contract agreements, members and their benefit entitlements, and clinical encounter submissions into a unified multi-domain master data management (MDM) architecture providing centralized interoperability between member MDM, health plan MDM, contract MDM, provider MDM, encounter MDM, and claims MDM data domains ….. the encounters module receives encounter data in a combination of structured and unstructured data input formats and transforms the encounter data into a structured data format defined by the platform framework suitable for payor operations” may all be characterized as improvements in the abstract idea using the additional elements (identified in the rejection) as tools in their ordinary capacity. Therefore, the Applicant’s arguments are not persuasive.
Response to Applicants’ arguments regarding Step 2A – Prong two:
According to MPEP 2106, limitations that are indicative of integration into a practical application include:
Improvements to the functioning of a computer, or to any other technology or technical field - see MPEP 2106.05(a)
Applying or using a judicial exception to effect a particular treatment or prophylaxis for a disease or medical condition
Applying the judicial exception with, or by use of, a particular machine - see MPEP 2106.05(b)
Effecting a transformation or reduction of a particular article to a different state or thing - see MPEP 2106.05(c)
Applying or using the judicial exception in some other meaningful way beyond generally linking the use of the judicial exception to a particular technological environment, such that the claim as a whole is more than a drafting effort designed to monopolize the exception - see MPEP 2106.05(e).
In the instant case, the judicial exception is not integrated into a practical application, because none of the above criteria is met. The claim (exemplary claim 1) only recites the additional elements of at least one user computing device, a user network, an application server in operable communication with the user network, a platform for automating healthcare insurance administration, the application system including a core enterprise system, an encounters module, a claims module, an intelligent data manager, artificial intelligence and machine learning, a centralized data repository comprising structured and unstructured data, an intelligent data manager, the MDMs and a user interface of the application system for providing access to the application system to perform all the steps. A plain reading of at least Figures 1-2I and descriptions in at least paragraphs [0005] – [0030] reveals that the at least one user computing device may be a generic user device like a laptop, a mobile telephone etc. The user network may be any generic wired or wireless network. The application server (including a core enterprise system) with a platform and a user interface may be a generic server suitably programmed to execute the claimed steps. The core enterprise system, an encounters module, a claims module, an intelligent data manager, the MDMs, artificial intelligence and machine learning are all broadly interpreted to include generic software suitably programmed to perform the associated functions. The centralized data repository comprising structured and unstructured data is broadly interpreted to include generic databases suitably programmed to store the respective data. The user interface of the application system for providing access to the application system is broadly interpreted to include generic software suitably programmed to perform the associated functions. Hence, the additional elements in the claims are all generic components suitably programmed to perform their respective functions. The additional elements in all the steps are recited at a high-level of generality (i.e., as generic computer components performing generic computer functions) such that it amounts no more than mere instructions to apply the exception using generic computer components. Accordingly, these additional elements do not integrate the abstract idea into a practical application because they do not impose any meaningful limits on practicing the abstract idea. Hence, the claims are directed to an abstract idea.
The Examiner does not see the parallel between the Applicant’s claims and those in Enfish, LLC v. Microsoft Corp., 822 F.3d 1327, 1337 (Fed. Cir. 2016) and/or Core Wireless Licensing S.A.R.L. v. LG Electronics, Inc., 880 F.3d 1356 (Fed. Cir. 2018). Therefore, the Applicant’s arguments are not persuasive.
The Examiner does not agree with the Applicant’s assertions (on pages 10-11 of the remarks) that activities such as “departments must manually re-classify data to process claims, manage provider directory, care delivery, utilization management, case management, benefit entitlements, open enrollment, and more” cannot be performed or made in the human mind. While these activities may be performed by a human mind slowly compared to a computer, these are still activities that a human is capable of performing. Using AI, Computer software or a different computer system to speed up the calculations does not materially alter the patent eligibility of the claimed subject matter, The fact that the required calculations could be performed more efficiently via a computer does not materially alter the patent eligibility of the claimed subject matter.”( See Bancorp Servs., L.L.C. v. Sun Life Assurance Co. of Can. (U.S.), 687 F.3d 1266, 1278 (Fed. Cir. 2012)); OIP Techs., Inc. v. Amazon.com, Inc., 788 F.3d 1359, 1363 (Fed. Cir. 2015) (relying on a computer to perform routine tasks more quickly or more accurately is insufficient to render a claims patent-eligible). Automating a manual process is insufficient to render a claim patent-eligible. See, e.g., Tranxition, Inc.v. Lenovo (U.S.) Inc., 664 F. App’x 968, 971 (Fed. Cir. 2016). The alleged benefits such as “making the processing less error-prone, reducing the additional overhead and decreasing operational cost …. providing interoperability across six MDM data domains, eliminating the need for departments to manually re-classify data between siloed systems ….. improving how healthcare data is organized, interrelated, and processed across domains …. presenting specific categories of real-time information including compliance alerts, fraud-detection notifications, and reimbursement status visualization ….. presenting specific, enumerated categories of healthcare data, member enrollment, eligibility, provider fee schedules, compliance alerts, fraud-detection notifications, overpayment recoveries, and reimbursement status, to authorized users in real time” are due to improvements in the abstract idea of a method for providing a platform for automating healthcare insurance administration. An improvement in abstract idea is still abstract (SAP America v. Investpic *2-3 (“We may assume that the techniques claimed are “groundbreaking, innovative, or even brilliant,” but that is not enough for eligibility. Association for Molecular Pathology v. Myriad Genetics, Inc., 569 U.S. 576, 591 (2013); accord buySAFE, Inc. v. Google, Inc., 765 F.3d 1350, 1352 (Fed. Cir. 2014). Nor is it enough for subject-matter eligibility that claimed techniques be novel and nonobvious in light of prior art, passing muster under 35 U.S.C. §§ 102 and 103. See Mayo Collaborative Servs. v. Prometheus Labs., Inc., 566 U.S. 66, 89–90 (2012); Synopsys, Inc. v. Mentor Graphics Corp., 839 F.3d 1138, 1151 (Fed. Cir. 2016) (“A claim for a new abstract idea is still an abstract idea). The additional elements (identified in the rejection) are generic computer components used to apply the abstract idea. It does not involve any improvements to another technology, technical field, or improvements to the functioning of the computer itself. Therefore, the Applicant’s arguments are not persuasive.
Response to Applicants’ arguments regarding Step 2B:
As discussed in the rejection, the claims do not include additional elements that are sufficient to amount to significantly more than the judicial exception. As discussed above with respect to integration of the abstract idea into a practical application, using the additional elements (identified in the rejection) to perform the claimed steps, amount to no more than mere instructions to apply the exception using a generic computer component. The additional elements of the instant underlying process, when taken in combination, together do not offer substantially more than the sum of the functions of the elements when each is taken alone. Mere instructions to apply an exception using a generic computer component cannot provide an inventive concept. Hence, the claims are not patent eligible.
As discussed in the rejection, the additional elements of the instant underlying process, when taken in combination, together do not offer substantially more than the sum of the functions of the elements when each is taken alone. The functions such as “The centralized MDM interoperability enabling the encounter module's data transformation, which feeds the claims module's automated reconciliation via EDI, which generates audit-ready records accessible through the real-time user interface. This pipeline, from multi-format encounter ingestion through MDM-mediated transformation to real-time compliance dashboards …. defining a specific data-management architecture (the centralized multi-domain MDM framework), a specific data-transformation process (structured and unstructured input to platform-defined structured output), specific processing operations (EDI-based claims reconciliation, fraud detection scoring, audit-ready record generation), and specific output configurations (real-time dashboards with enumerated data categories)” are all conventional functions of a computer system (that is suitably programmed to perform the associated functions). These activities do not involve any improvements to another technology, technical field, or improvements to the functioning of the computer itself. By relying on a computer system to perform routine tasks more quickly or more accurately is insufficient to render a claim patent eligible (See Alice, 134 S. Ct. at 2359 (use of a computer to create electronic records, track multiple transactions, and issue simultaneous instructions” is not an inventive concept). The alleged benefits such as “reducing the cost to consumers by facilitating improved, automated processes for data management and reporting in the healthcare insurance industry” are due to improvements in the abstract idea of a system and method for providing a platform for automating healthcare insurance administration, using the additional element (identified in the rejection) as tools in their ordinary capacity. An improvement in abstract idea is still abstract (SAP America v. Investpic *2-3 (“We may assume that the techniques claimed are “groundbreaking, innovative, or even brilliant,” but that is not enough for eligibility. Association for Molecular Pathology v. Myriad Genetics, Inc., 569 U.S. 576, 591 (2013); accord buySAFE, Inc. v. Google, Inc., 765 F.3d 1350, 1352 (Fed. Cir. 2014).The Applicant’s claims do not recite sufficient subject matter to take them from being in the realm of what is encompassed as an abstract idea into patentable subject matter and fail to add significantly more to “transform” the nature of the claims. Therefore, the Applicant’s arguments are not persuasive.
For these reasons and those discussed in the rejection, the rejections under 35 USC § 101 are maintained.
Conclusion
5. The prior art made of record and not relied upon is considered pertinent to applicant's disclosure:
(a) McNair; Douglas S. (US Pub. 2024/0095845 A1) discloses systems and methods for the problem of automatic, algorithm-guided estimation of insurance loss ratio, claims frequency, the probability of excess claims, and other insurance policy performance characteristics for an individual insured or for groups of insured individuals. A time-series-derived Bayesian power spectrum weight is calculated from the frequency of temporal pattern-specific values in terms of intensities at various frequencies of the power spectrum computed from credit utilization ratio (CUR; outstanding balance of debt, as a percentage of credit line available) time-series obtained by the insurer by ‘soft pull’ inquiries submitted periodically to credit-rating agencies, and provides an opportunity to capture and measure the relative magnitude of frequent or unexpected changes in consumer liquidity. The present technology provides a system and method for classifying insurance risk, for insurance risk scoring, or for incorporating a power-spectrum-based temporal pattern-specific weight into an actuarial method to enhance the loss ratio estimation accuracy and statistic
6. Applicant's amendment necessitated the new ground(s) of rejection presented in this Office action. Accordingly, THIS ACTION IS MADE FINAL. See MPEP § 706.07(a). Applicant is reminded of the extension of time policy as set forth in 37 CFR 1.136(a).
A shortened statutory period for reply to this final action is set to expire THREE MONTHS from the mailing date of this action. In the event a first reply is filed within TWO MONTHS of the mailing date of this final action and the advisory action is not mailed until after the end of the THREE-MONTH shortened statutory period, then the shortened statutory period will expire on the date the advisory action is mailed, and any extension fee pursuant to 37 CFR 1.136(a) will be calculated from the mailing date of the advisory action. In no event, however, will the statutory period for reply expire later than SIX MONTHS from the date of this final action.
Any inquiry concerning this communication or earlier communications from the Examiner should be directed to Narayanswamy Subramanian whose telephone number is (571) 272-6751. The examiner can normally be reached Monday-Friday from 9:00 AM to 5:00 PM. If attempts to reach the examiner by telephone are unsuccessful, the examiner's supervisor, Abhishek Vyas can be reached at (571) 270-1836. The fax number for Formal or Official faxes and Draft to the Patent Office is (571) 273-8300.
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/Narayanswamy Subramanian/
Primary Examiner
Art Unit 3691
March 19, 2026