DETAILED ACTION
Notice of Pre-AIA or AIA Status
The present application, filed on or after March 16, 2013, is being examined under the first inventor to file provisions of the AIA .
Continued Examination Under 37 CFR 1.114
A request for continued examination under 37 CFR 1.114, including the fee set forth in 37 CFR 1.17(e), was filed in this application after final rejection. Since this application is eligible for continued examination under 37 CFR 1.114, and the fee set forth in 37 CFR 1.17(e) has been timely paid, the finality of the previous Office action has been withdrawn pursuant to 37 CFR 1.114. Applicant's submission filed on March 13, 2026 has been entered.
Response to Amendment
In the amendment filed on March 13, 2026, the following has occurred: claim(s) 1, 11 have been amended. Now, claim(s) 1-5, 7-15, 17-20 are pending.
Claim Rejections - 35 USC § 101
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.
Claim(s) 1-5, 7-15, 17-20 is/are rejected under 35 U.S.C. 101 because the claimed invention is directed to an abstract idea without significantly more.
Claims 1-5, 7-10: Step 2A Prong One
Claim 1 recites:
receive a set of patient information associated with the patient, wherein the set of patient information includes at least an insurance provider identifier;
create a patient account data structure using a data structure template by recording the insurance provider identifier received in the set of patient information into the insurance provider identifier data field, wherein the data structure template has the same data fields as the plurality of data structures;
query for data structures with the same insurance provider identifier as the insurance provider identifier of the patient account data structure;
after locating a data structure with the same insurance provider identifier, automatically record benefits data in the medical benefits data fields of the data structure into the medical benefits data fields of the patient account data structure so that the patient account data structure includes information indicative of a copay amount, an out-of-pocket maximum amount, and a deductible amount; and
store the patient account data structure
These limitations, as drafted, given the broadest reasonable interpretation, but for the recitation of generic computer components, encompass managing personal behavior or
relationships or interactions between people (including social activities, teaching, and following rules or instructions), which is a subgrouping of Certain Methods of Organizing Human Activity. That is, other than reciting, “a memory device having a plurality of data structures, wherein the plurality of data structures include predetermined data fields that comprise at least medical benefits data fields and an insurance provider identifier data field, the medical benefits data fields including at least a copay amount data field, an out-of-pocket maximum data field, and a deductible data field,”, “a server communicatively coupled to the memory device via a network”, “…a healthcare provider computer over the network…”, “…the memory device…”, “…a patient information database that is communicatively coupled via the network to the server” to perform these functions, nothing in the claim precludes the limitations from practically being performed by hospital staff, a claims agent, or another similar position staffed by a person. For example, the claims encompass a person manually following instructions to receive a set of patient information associated with the patient, a person manually following instructions to create a patient account data structure using a data structure template by recording the insurance provider identifier received in the set of patient information into the insurance provider identifier data field, a person manually following instructions to query a database to identify the same insurance provider identifier as the insurance provider identifier of the patient account data structure, a person manually following instructions to automatically record benefits data in the medical benefits data fields of the data structure into the medical benefits data fields of the patient account data structure, so that the patient account data structure includes information indicative of a copay amount, an out-of-pocket maximum amount, and a deductible amount, and a person manually following instructions to store the patient account data structure.
Claims 2-5, 7-10 incorporate the abstract idea identified above and recite additional limitations that expand on the abstract idea, but for the recitation of generic computer components. For example, claim 2 includes the abstract idea identified above and further describes the set of patient information. Similarly, claim 3 includes the abstract idea identified above and further describes the data structure template. Similarly, claim 4 includes the abstract idea identified above and further describes populating the medical benefit data fields of the patient account data structure. Similarly, claim 5 includes the abstract idea identified above and further describes the insurance provider identifier. Similarly, claims 7-8 include the abstract idea identified above and further describe determining eligible insurance coverage and steps if the insurance provider identifier and medical benefits are eligible or not eligible. Finally, claims 9-10 include the abstract idea identified above and describe a verification note. Such steps encompass Certain Methods of Organizing Human Activity.
Claims 1-5, 7-10: Step 2A Prong Two
This judicial exception is not integrated into a practical application because the remaining elements amount to no more than general purpose computer components programmed to perform the abstract idea.
Claims 1-5, 7-10, directly or indirectly, recite the following generic computer components, “a memory device having a plurality of data structures, wherein the plurality of data structures include predetermined data fields that comprise at least medical benefits data fields and an insurance provider identifier data field, the medical benefits data fields including at least a copay amount data field, an out-of-pocket maximum data field, and a deductible data field”, “a server communicatively coupled to the memory device via a network”, “…a healthcare provider computer over the network…”, “…the memory device…”, “…a patient information database that is communicatively coupled via the network to the server” (i.e., “The server 130 is configured to receive a set of patient information from a provider module 120 (e.g., a healthcare provider computer) via a network 110. The provider module 120 comprises a desktop computer, a laptop computer, a smartphone, a processor, a logic controller, a computer network, or any combination thereof that is operated by a healthcare provider. In one embodiment, the provider module 120 includes software defined by machine readable instructions. Execution of the instructions by a processor of the provider module 120 provides a prompt and/or data fields for a user to input information related to a patient. The information may include the patient's first name, last name, date of birth, insurance identification number, insurance group information, etc.” (See Specification in Paragraph [0034]), “In one embodiment, the server 130 stores the patient account data structure 720 in the patient information database 170. Additionally or alternatively, the server 130 transmits the patient account data structure 720 to the provider module 120. Otherwise, the server 130 makes the patient account data structure 720 available to the provider module 120. The server 130 may further use the patient account data structure 720 for requests with patient information that is received from other provider modules 120.” (See Specification in Paragraph [0053])) As set forth in the 2019 Eligibility Guidance, 84 Fed. Reg. at 55 “merely include[ing] instructions to implement an abstract idea on a computer" is an example of when an abstract idea has not been integrated into a practical application.
Claims 1-5, 7-10: Step 2B
The claim(s) does/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, the additional elements of using a computer configured to perform above identified functions amounts to no more than mere instructions to apply the exception using generic computer components. Mere instructions to apply an exception using a generic computer component cannot provide an inventive concept. See Alice 573 U.S. at 223 (“mere recitation of a generic computer cannot transform a patent-ineligible abstract idea
into a patent-eligible invention.”)
Looking at the limitations as an ordered combination adds nothing that is not already
present when looking at the elements taken individually. There is no indication that the
combination of elements improves the functioning of a computer or improves any other technology. Their collective functions merely provide conventional computer implementation
and do not impose a meaningful limit to integrate the abstract idea into a practical application.
The claims are not patent eligible.
Claims 11-15, 17-20 recite the same functions as claims 1-5, 7-10, but in method form.
Therefore, whether considered alone or in combination, the additional elements do not
amount to significantly more than the abstract idea.
Claim Rejections - 35 USC § 103
In the event the determination of the status of the application as subject to AIA 35 U.S.C. 102 and 103 (or as subject to pre-AIA 35 U.S.C. 102 and 103) is incorrect, any correction of the statutory basis (i.e., changing from AIA to pre-AIA ) for the rejection will not be considered a new ground of rejection if the prior art relied upon, and the rationale supporting the rejection, would be the same under either status.
The following is a quotation of 35 U.S.C. 103 which forms the basis for all obviousness rejections set forth in this Office action:
A patent for a claimed invention may not be obtained, notwithstanding that the claimed invention is not identically disclosed as set forth in section 102, if the differences between the claimed invention and the prior art are such that the claimed invention as a whole would have been obvious before the effective filing date of the claimed invention to a person having ordinary skill in the art to which the claimed invention pertains. Patentability shall not be negated by the manner in which the invention was made.
The factual inquiries for establishing a background for determining obviousness under 35 U.S.C. 103 are summarized as follows:
1. Determining the scope and contents of the prior art.
2. Ascertaining the differences between the prior art and the claims at issue.
3. Resolving the level of ordinary skill in the pertinent art.
4. Considering objective evidence present in the application indicating obviousness or nonobviousness.
Claims 1-5, 11-15 are rejected under 35 U.S.C. 103 as being unpatentable over Bose (U.S. Patent Pre-Grant Publication No. 2023/0352154) in view of Wales et al. (U.S. Patent Pre-Grant Publication No. 2020/0234377) in further view of Brekka et al. (U.S. Patent Pre-Grant Publication No. 2019/0114719).
As per independent claim 1, Bose discloses a system for automatically verifying medical benefits information, the system comprising: a memory device having a plurality of data structures, wherein the plurality of data structures include predetermined data fields that comprise at least medical benefits data fields and an insurance provider identifier data field (See Paragraphs [0111], [0153]-[0171]: If the claim being searched for is present in the list displayed as a result of the search, the user may skip to verifying that the claim is correct, which the Examiner is interpreting to encompass the claimed portion as the provider database ([0153]) is interpreted to encompass a memory device having a plurality of data structures, interpreting the healthcare claims ([0111]) and DOS field ([0159]) to encompass medical benefits data fields, and the Payer Name field ([0160]) to encompass an insurance provider identifier data field), the medical benefits data fields including at least a copay amount data field, an out-of-pocket maximum data field, and a deductible data field, wherein the data structures in the memory device are organized by an insurance group identification number (See Paragraphs [0074], [0104]-[0105], [0122]: Machine learning-based software assembles data into an organized format using one or more unsupervised learning techniques, which the Examiner is interpreting an organized format to encompass organized by the insurance group identification number as key data can include an identifier number ([0122])); and
a server communicatively coupled to the memory device via a network (See Paragraphs [0070]-[0071]: The system includes functions executed in software by a computing device connected to a network, and the computing device can include one or more servers that can be located locally or remotely from users), the server configured to: receive a set of patient information associated with the patient from a healthcare provider computer over the network, wherein the set of patient information includes at least an insurance provider identifier (See Paragraphs [0054]-[0060], [0070]: The healthcare data is analyzed, analyzing the healthcare data may include extracting key data from the received healthcare data, the key data extracted from the received healthcare data may include: date of birth, invoice number, claim data, identifier number, patient name, phone number, fax number, expiration data, provider name, billed amount, proposed amount, keywords, paid amount, co-insurance, deductible, claim adjustment reason code (CARC), remittance advice remark codes (RARC), place of service (POS), elective versus emergency room (ER) indication, insurance (INS) claim number, and authorization, which the Examiner is interpreting the healthcare data to encompass a set of patient information associated with the patient from a healthcare provider computer over the network ([0070]), and the claim data, co-insurance to encompass an insurance provider identifier);
create a patient account data structure using a data structure template by recording the insurance provider identifier received in the set of patient information into the insurance provider identifier data field, wherein the data structure template has the same data fields as the plurality of data structures in the memory device (See Paragraphs [0066]-[0068]: The appeal letter generated by the system may be based on the healthcare data received (e.g., claim denial), the instructions received from the user (file an appeal), and an analysis of the data, this analysis can include populating one of a plurality of template appeal letters based on the data, which the Examiner is interpreting the appeal letter generated by the system may be based on the healthcare data received (e.g., claim denial) to encompass create a patient account data structure using a data structure template by recording the insurance provider identifier received in the set of patient information into the insurance provider identifier data field, and this analysis can include populating one of a plurality of template appeal letters based on the data to encompass wherein the data structure template has the same data fields as the plurality of data structures in the memory device);
after locating a data structure in the memory device with the same insurance provider identifier, automatically record medical benefits data in the medical benefits data fields of the data structure in the memory device into the medical benefits data fields of the patient account data structure (See Paragraphs [0066]-[0068]: The appeal letter generated by the system may be based on the healthcare data received (e.g., claim denial), the instructions received from the user (file an appeal), and an analysis of the data, this analysis can include populating one of a plurality of template appeal letters based on the data, which the Examiner is interpreting analysis can include populating one of a plurality of template appeal letters based on the data to encompass automatically record medical benefits data in the medical benefits data fields of the data structure in the memory device into the medical benefits data fields of the patient account data structure when combined with Wales as disclosed below) so that the patient account data structure includes information indicative of a copay amount, an out-of-pocket maximum amount, and a deductible amount; and
store the patient account data structure in a patient information database that is communicatively coupled via the network to the server (See Paragraphs [0098]-[0100], [0187]-[0189]: Analysis module may be configured to analyze the received raw healthcare data to make a determination and/or generate new or additional data which may also be stored in database, which the Examiner is interpreting generate new or additional data which may also be stored in database to encompass the claimed portion.)
While Bose teaches the system as described above, Bose may not explicitly teach a server communicatively coupled to the memory device via a network, the server configured to: query the memory device for data structures with the same insurance provider identifier as the insurance provider identifier of the patient account data structure.
Wales teaches a system for a server communicatively coupled to the memory device via a network, the server configured to: query the memory device for data structures with the same insurance provider identifier as the insurance provider identifier of the patient account data structure (See Paragraphs [0129]-[0132]: Using the identification number of the customer (patient) the situation oracle of the insurer, assess or triages the service situation contracts on the blockchain against the potential coverages for all of the medical policies held by that insurer for that particular patient, and as the insurance oracle is on the insurer's node, it is able to access all polices for all persons held by that insurer, matching the identification number of the customer (patient) for which the treatment/service situation has been raised, which the Examiner is interpreting the insurance oracle is on the insurer's node, it is able to access all polices for all persons held by that insurer, matching the identification number of the customer (patient) for which the treatment/service situation has been raised to encompass the claimed portion.)
It would have been obvious to one of ordinary skill in the art before the effective filing date of the claimed to modify the system of Bose to include a server communicatively coupled to the memory device via a network, the server configured to: query the memory device for data structures with the same insurance provider identifier as the insurance provider identifier of the patient account data structure as taught by Wales. One of ordinary skill in the art before the effective filing date of the claimed invention would have been motivated to modify Bose with Wales with the motivation of addressing inefficiencies between insured, insurers and providers (See Background of Wales in Paragraphs [0003]-[0006]).
While Bose/Wales teaches the system comprising:
a memory device having a plurality of data structures, wherein the plurality of data structures include predetermined data fields that comprise at least medical benefits data fields and an insurance provider identifier data field, wherein the data structures in the memory device are organized by an insurance group identification number; and
after locating a data structure in the memory device with the same insurance provider identifier, automatically record medical benefits data in the medical benefits data fields of the data structure in the memory device into the medical benefits data fields of the patient account data structure, Bose/Wales may not explicitly teach a memory device having a plurality of data structures, wherein the plurality of data structures include predetermined data fields that comprise at least medical benefits data fields and an insurance provider identifier data field, the medical benefits data fields including at least a copay amount data field, an out-of-pocket maximum data field, and a deductible data field, wherein the data structures in the memory device are organized by an insurance group identification number; and
after locating a data structure in the memory device with the same insurance provider identifier, automatically record medical benefits data in the medical benefits data fields of the data structure in the memory device into the medical benefits data fields of the patient account data structure so that the patient account data structure includes information indicative of a copay amount, an out-of-pocket maximum amount, and a deductible amount.
Brekka teaches a system for a memory device having a plurality of data structures, wherein the plurality of data structures include predetermined data fields that comprise at least medical benefits data fields and an insurance provider identifier data field, the medical benefits data fields including at least a copay amount data field, an out-of-pocket maximum data field, and a deductible data field (See Fig. 2 and Paragraphs [0033]-[0036], [0056]-[0057]: In the estimator engine, patient coverage is verified, including copays, coinsurance, deductible and out-of-pocket information upfront through eligibility requests/responses using the EDI 270/271 standard, which the Examiner is interpreting copays, coinsurance, deductible and out-of-pocket information upfront through eligibility requests/responses to encompass the medical benefits data fields including at least a copay amount data field, an out-of-pocket maximum data field, and a deductible data field), wherein the data structures in the memory device are organized by an insurance group identification number; and
after locating a data structure in the memory device with the same insurance provider identifier, automatically record medical benefits data in the medical benefits data fields of the data structure in the memory device into the medical benefits data fields of the patient account data structure so that the patient account data structure includes information indicative of a copay amount, an out-of-pocket maximum amount, and a deductible amount (See Fig. 2 and Paragraphs [0033]-[0036], [0056]-[0057]: In the estimator engine, patient coverage is verified, including copays, coinsurance, deductible and out-of-pocket information upfront through eligibility requests/responses using the EDI 270/271 standard, which the Examiner is interpreting copays, coinsurance, deductible and out-of-pocket information upfront through eligibility requests/responses to encompass the patient account data structure includes information indicative of a copay amount, an out-of-pocket maximum amount, and a deductible amount.)
It would have been obvious to one of ordinary skill in the art before the effective filing date of the claimed to modify the system of Bose/Wales to include the medical benefits data fields including at least a copay amount data field, an out-of-pocket maximum data field, and a deductible data field; and the patient account data structure includes information indicative of a copay amount, an out-of-pocket maximum amount, and a deductible amount as taught by Brekka. One of ordinary skill in the art before the effective filing date of the claimed invention would have been motivated to modify Bose/Wales with Brekka with the motivation of effectively communicating to patients about the expected financial responsibilities at or prior the time of service (See Background of the Invention of Brekka in Paragraph [0005]).
Claim(s) 11 mirrors claim 1 only within a different statutory category, and is rejected for the same reason as claim 1.
The addition of “storing a plurality of data structures in a memory device, wherein the plurality of data structures include predetermined data fields that comprise at least medical benefits data fields and an insurance provider identifier data field, the medical benefits data fields including at least a copay amount data field, an out-of-pocket maximum data field, and a deductible data field, wherein the data structures in the memory device are organized by an insurance group identification number;” is encompassed by Bose in Paragraphs [0074]-[0075]: “The system may further comprise software- or hardware-based modules and database(s) for processing and storing content associated with the system, metadata generated by the system for each piece of content, user preferences, and the like.”, Paragraphs [0111], [0153]-[0171]: If the claim being searched for is present in the list displayed as a result of the search, the user may skip to verifying that the claim is correct, which the Examiner is interpreting to encompass the claimed portion as the provider database ([0153]) is interpreted to encompass a memory device having a plurality of data structures, interpreting the healthcare claims ([0111]) and DOS field ([0159]) to encompass medical benefits data fields, and the Payer Name field ([0160]) to encompass an insurance provider identifier data field, and in Paragraphs [0074], [0104]-[0105], [0122]: Machine learning-based software assembles data into an organized format using one or more unsupervised learning techniques, which the Examiner is interpreting an organized format to encompass organized by the insurance group identification number as key data can include an identifier number ([0122]).
As per claim 2, Bose/Wales/Brekka discloses the system of claim 1 as described above. Bose further teaches wherein the set of patient information further comprises a first name, a last name, a date of birth, a member identification number, or a group identification number associated with the patient (See Paragraph [0060]:The key data extracted from the received healthcare data may include: date of birth, invoice number, claim data, identifier number, patient name, phone number, fax number, expiration data, provider name, billed amount, proposed amount, keywords, paid amount, co-insurance, deductible, claim adjustment reason code (CARC), remittance advice remark codes (RARC), place of service (POS), elective versus emergency room (ER) indication, insurance (INS) claim number, and authorization.)
Claim(s) 12 mirrors claim 2 only within a different statutory category, and is rejected for the same reason as claim 2.
As per claim 3, Bose/Wales/Brekka discloses the system of claim 1 as described above. Bose further teaches wherein the predetermined data fields of the plurality of data structures in the memory device and the data structure template comprise an insurance status, an insurance type, an insurance policy type, an insurance provider company name, a set of insurance company contact information, an insurance policy number, an insurance category number, an insurance group number, an insurance term date, a set of policyholder information, co-pay data, reimbursement data, deductible data, out-of-pocket data, a set of medical equipment guidelines, and a set of prescription authorizations (See Fig. 4, 5A-5C and Paragraphs [0052], [0060], [0100]-[0101]: The appeal letter may be automatically generated, if instructed to do so based on user instructions, based on these determinations and the underlying healthcare data, which the Examiner is interpreting the appeal template to encompass the data structure template, and the key data extracted from the received healthcare data may include: date of birth, invoice number, claim data, identifier number, patient name, phone number, fax number, expiration data, provider name, billed amount, proposed amount, keywords, paid amount, co-insurance, deductible, claim adjustment reason code (CARC), remittance advice remark codes (RARC), place of service (POS), elective versus emergency room (ER) indication, insurance (INS) claim number, and authorization to encompass an insurance status, an insurance type, an insurance policy type, an insurance provider company name, a set of insurance company contact information, an insurance policy number, an insurance category number, an insurance group number, an insurance term date, a set of policyholder information, co-pay data, reimbursement data, deductible data, out-of-pocket data, a set of medical equipment guidelines, and a set of prescription authorizations.)
Claim(s) 13 mirrors claim 3 only within a different statutory category, and is rejected for the same reason as claim 3.
As per claim 4, Bose/Wales/Brekka discloses the system of claim 1 as described above. Bose may not explicitly teach wherein, when populating the medical benefits data fields of the patient account data structure, the server when further configured to, after an unsuccessful match, automatically transmits a message to the healthcare provider computer, via the network, that prompts the healthcare provider to request medical benefits data from the patient.
Wales teaches a system wherein, when populating the medical benefits data fields of the patient account data structure, the server when further configured to, after an unsuccessful match, automatically transmits a message to the healthcare provider computer, via the network, that prompts the healthcare provider to request medical benefits data from the patient (See Paragraphs [0029]-[0030], [0035]: An indication of whether the submission resulted in a successful response or if an error response was returned, if an error response was returned, the information may include information indicating a reason for the error, and as he user enters information into each field, the prediction engine may check the entered information for any errors, an indication may be provided and presented to the user regarding why the submission is likely to result in an error and/or what corrections the user should make to try to avoid the error, which the Examiner is interpreting an indication may be provided and presented to the user regarding why the submission is likely to result in an error and/or what corrections the user should make to try to avoid the error to encompass prompts the healthcare provider to request medical benefits data from the patient, and interpreting error to encompass an unsuccessful match.)
It would have been obvious to one of ordinary skill in the art before the effective filing date of the claimed to modify the system of Bose to include when populating the medical benefits data fields of the patient account data structure, the server when further configured to, after an unsuccessful match, automatically transmits a message to the healthcare provider computer, via the network, that prompts the healthcare provider to request medical benefits data from the patient as taught by Wales. One of ordinary skill in the art before the effective filing date of the claimed invention would have been motivated to modify Bose with Wales with the motivation of addressing inefficiencies between insured, insurers and providers (See Background of Wales in Paragraphs [0003]-[0006]).
Claim(s) 14 mirrors claim 4 only within a different statutory category, and is rejected for the same reason as claim 4.
As per claim 5, Bose/Wales/Brekka discloses the system of claim 1 as described above. Bose further teaches wherein the insurance provider identifier corresponds to the insurance group identification number (See Paragraph [0167]: The NPI field may be used to enter the provider's GROUP NPI number.)
Claim(s) 15 mirrors claim 5 only within a different statutory category, and is rejected for the same reason as claim 5.
Claims 7-10, 17-20 are rejected under 35 U.S.C. 103 as being unpatentable over Bose (U.S. Patent Pre-Grant Publication No. 2023/0352154) in view of Wales et al. (U.S. Patent Pre-Grant Publication No. 2020/0234377) in view of Brekka et al. (U.S. Patent Pre-Grant Publication No. 2019/0114719) in further view of Flam et al. (U.S. Patent Pre-Grant Publication No. 2008/0027760).
As per claim 7, Bose/Wales/Brekka discloses the system of claim 1 as described above. Bose/Wales/Brekka may not explicitly teach wherein the server is further configured to, after the patient account data structure is stored:
determine whether the insurance provider identifier stored within the patient account data structure corresponds to eligible insurance coverage provided by another healthcare provider computer or the same healthcare provider computer;
when the insurance provider identifier does not correspond to the eligible insurance coverage, transmit a hold message; and
when the insurance provider identifier corresponds to the eligible insurance coverage, transmit an indication of the eligible insurance coverage.
Flam teaches a system wherein the server is further configured to, after the patient account data structure is stored:
determine whether the insurance provider identifier stored within the patient account data structure corresponds to eligible insurance coverage provided by another healthcare provider computer or the same healthcare provider computer (See Paragraphs [0042]-[0044]: The requesting computer receives a positive or a negative response, data captured from the eligibility response is stored in a memory device such as a database, and the data can be quickly retrieved when the patient returns and eligibility needs to be confirmed again, which the Examiner is interpreting the requesting computer to encompass the same healthcare provider computer, and data captured from the eligibility response is stored in a memory device such as a database to encompass determine whether the insurance provider identifier stored within the patient account data structure corresponds to eligible insurance coverage);
when the insurance provider identifier does not correspond to the eligible insurance coverage, transmit a hold message (See Paragraphs [0042]-[0044]: A negative response can indicate that no record was found for the person whose eligibility is being requested or, in the alternative, the record was found but the person does not have an active membership with the payer institution, which the Examiner is interpreting a negative response to encompass the insurance provider identifier does not correspond to the eligible insurance coverage, and the record was found but the person does not have an active membership with the payer institution to encompass a hold message); and
when the insurance provider identifier corresponds to the eligible insurance coverage, transmit an indication of the eligible insurance coverage (See Paragraphs [0042]-[0044]: A negative response can indicate that no record was found for the person whose eligibility is being requested or, in the alternative, the record was found but the person does not have an active membership with the payer institution, which the Examiner is interpreting a positive response indicates that the payer computer found a record corresponding to the person whose eligibility is being requested to encompass the insurance provider identifier corresponds to the eligible insurance coverage, and data captured from the eligibility response is stored in a memory device such as a database to encompass an indication of the eligible insurance coverage.)
It would have been obvious to one of ordinary skill in the art before the effective filing date of the claimed to modify the system of Bose/Wales/Brekka to include determine whether the insurance provider identifier stored within the patient account data structure corresponds to eligible insurance coverage provided by another healthcare provider computer or the same healthcare provider computer; when the insurance provider identifier does not correspond to the eligible insurance coverage, transmit a hold message; and when the insurance provider identifier corresponds to the eligible insurance coverage, transmit an indication of the eligible insurance coverage as taught by Flam. One of ordinary skill in the art before the effective filing date of the claimed invention would have been motivated to modify Bose/Wales/Brekka with Flam with the motivation of improving time efficiency for a healthcare eligibility and benefits data system (See Detailed Description of Exemplary Embodiments of Flam in Paragraphs [0028]-[0029]).
Claim(s) 17 mirrors claim 7 only within a different statutory category, and is rejected for the same reason as claim 7.
As per claim 8, Bose/Wales discloses the system of claim 1 as described above. Bose/Wales may not explicitly teach wherein the server is further configured to, after the patient account data structure is stored:
determine whether the medical benefits data stored within the patient account data structure corresponds to eligible insurance coverage provided by another healthcare provider computer or the same healthcare provider computer;
when the medical benefits data does not correspond to the eligible insurance coverage, transmit a hold message indicative that the patient does not possess necessary medical benefits; and
when the medical benefits data corresponds to the eligible insurance coverage, transmit an indication of the valid medical benefits.
Flam teaches a system wherein the server is further configured to, after the patient account data structure is stored:
determine whether the medical benefits data stored within the patient account data structure corresponds to eligible insurance coverage provided by another healthcare provider computer or the same healthcare provider computer (See Paragraphs [0042]-[0044]: The requesting computer receives a positive or a negative response, data captured from the eligibility response is stored in a memory device such as a database, and the data can be quickly retrieved when the patient returns and eligibility needs to be confirmed again, which the Examiner is interpreting the determine whether the medical benefits data stored within the patient account data structure corresponds to eligible insurance coverage provided by the same healthcare provider computer);
when the medical benefits data does not correspond to the eligible insurance coverage, transmit a hold message indicative that the patient does not possess necessary medical benefits (See Paragraphs [0042]-[0044]: A negative response can indicate that no record was found for the person whose eligibility is being requested or, in the alternative, the record was found but the person does not have an active membership with the payer institution, which the Examiner is interpreting a negative response to encompass the medical benefits data does not correspond to the eligible insurance coverage, and the record was found but the person does not have an active membership with the payer institution to encompass a hold message indicative that the patient does not possess necessary medical benefits); and
when the medical benefits data corresponds to the eligible insurance coverage, transmit an indication of the valid medical benefits (See Paragraphs [0042]-[0044]: A negative response can indicate that no record was found for the person whose eligibility is being requested or, in the alternative, the record was found but the person does not have an active membership with the payer institution, which the Examiner is interpreting a positive response indicates that the payer computer found a record corresponding to the person whose eligibility is being requested to encompass the medical benefits data corresponds to the eligible insurance coverage, and data captured from the eligibility response is stored in a memory device such as a database to encompass an indication of the valid medical benefits.)
It would have been obvious to one of ordinary skill in the art before the effective filing date of the claimed to modify the system of Bose/Wales/Brekka to include determine whether the medical benefits data stored within the patient account data structure corresponds to eligible insurance coverage provided by another healthcare provider computer or the same healthcare provider computer; when the medical benefits data does not correspond to the eligible insurance coverage, transmit a hold message indicative that the patient does not possess necessary medical benefits; and when the medical benefits data corresponds to the eligible insurance coverage, transmit an indication of the valid medical benefits as taught by Flam. One of ordinary skill in the art before the effective filing date of the claimed invention would have been motivated to modify Bose/Wales/Brekka with Flam with the motivation of improving time efficiency for a healthcare eligibility and benefits data system (See Detailed Description of Exemplary Embodiments of Flam in Paragraphs [0028]-[0029]).
Claim(s) 18 mirrors claim 8 only within a different statutory category, and is rejected for the same reason as claim 8.
As per claim 9, Bose/Wales/Brekka discloses the system of claim 1 and Bose/Wales/Brekka/Flam discloses the system of claim 8 as described above. Bose/Wales/Brekka may not explicitly teach wherein the server is further configured to add a verification note to the patient account data structure when the medical benefits data corresponds to the eligible insurance coverage.
Flam teaches a system wherein the server is further configured to add a verification note to the patient account data structure when the medical benefits data corresponds to the eligible insurance coverage (See Paragraphs [0041]-[0044]: The membership number or identifier and other personal information can be captured in the format accepted by the payer computer because the information is taken from data sent by the payer computer, which the Examiner is interpreting to encompass the claimed portion as the positive response can be stored in a memory device.)
It would have been obvious to one of ordinary skill in the art before the effective filing date of the claimed to modify the system of Bose/Wales/Brekka to include the server is further configured to add a verification note to the patient account data structure when the medical benefits data corresponds to the eligible insurance coverage as taught by Flam. One of ordinary skill in the art before the effective filing date of the claimed invention would have been motivated to modify Bose/Wales/Brekka with Flam with the motivation of improving time efficiency for a healthcare eligibility and benefits data system (See Detailed Description of Exemplary Embodiments of Flam in Paragraphs [0028]-[0029]).
Claim(s) 19 mirrors claim 9 only within a different statutory category, and is rejected for the same reason as claim 9.
As per claim 10, Bose/Wales/Brekka discloses the system of claim 1 and Bose/Wales/Brekka/Flam discloses the system of claims 8-9 as described above. Bose/Wales/Brekka may not explicitly teach wherein the verification note includes a date and/or time when the medical benefits data was verified.
Flam teaches a system wherein the verification note includes a date and/or time when the medical benefits data was verified (See Paragraphs [0009], [0044]: The methods may also verify the received information before the received information is communicated, the methods may provide a list of candidates for whom information is stored and, upon selection of one candidate from the list of candidates, the methods retrieve stored information associated with the selected candidate, patient eligibility may change from one visit to the next and it can be costly to the provider if services are performed for patients who are no longer eligible for a particular service, which the Examiner is interpreting patient eligibility may change from one visit to the next to encompass the verification note includes a date and/or time when the medical benefits data was verified as the eligibility response is stored in a memory device such as a database.)
It would have been obvious to one of ordinary skill in the art before the effective filing date of the claimed to modify the system of Bose/Wales/Brekka to include the verification note includes a date and/or time when the medical benefits data was verified as taught by Flam. One of ordinary skill in the art before the effective filing date of the claimed invention would have been motivated to modify Bose/Wales/Brekka with Flam with the motivation of improving time efficiency for a healthcare eligibility and benefits data system (See Detailed Description of Exemplary Embodiments of Flam in Paragraphs [0028]-[0029]).
Claim(s) 20 mirrors claim 10 only within a different statutory category, and is rejected for the same reason as claim 10.
Response to Arguments
In the Remarks filed on March 13, 2026, the Applicant argues that the newly amended and/or added claims overcome the 35 U.S.C. 101 rejection(s), and 35 U.S.C. 103 rejection(s). The Examiner does not acknowledge that the newly added and/or amended claims overcome the 35 U.S.C. 101 rejection(s) and 35 U.S.C. 103 rejection(s).
The Applicant argues that:
(1) Bose and Wales fail to disclose the above-features of present Claims 1 and 11. Bose instead discloses a system that facilitates the exchange of insurance claim data between companies. (See Bose, pars. [0114] and [0115]). Bose discloses that the system also permits users to automatically generate an appeal letter related to an insurance coverage decision. (See Bose, pars. [0144] to [0148]). Bose mentions that the appeal letter may be automatically populated with some information from an insurance claim. (See Bose, pars. [0144] to [0148]). Bose is silent about creating a patient account data structure by, in part, pulling insurance benefit data from a data structure that includes listed benefits for a corresponding insurance provider of the patient using an identifier of the insurance provider. Bose is focused instead on the interoperability of insurance information between different companies. (See Bose, pars. [0107] and [0109]). For this reason, present independent Claims 1 and 11 are patentable over Bose. Wales fails to cure the deficiencies of Bose. Wales is directed to processing insurance
transactions, not creating a patient account data structure with insurance benefits information. While Wales discloses the use of insurance policies, Wales contemplates separately accessing a specific insurance policy (51) to pull benefits information for processing a transaction. (See Wales, pars. [0073] and [0180] to [0185]). Wales is silent about creating a data structure for a patient with benefits data that is pulled from a specific policy (51). In view thereof, independent Claims 1 and 11 (and dependent Claims 2 to 5 and 12 to 15) are patentable over Wales in any combination with Bose. Flam is not cited for, nor does the reference remedy the foregoing deficiencies in Bose or Wales. As such, present independent Claims 1 and 11 are patentable over Bose, Wales, and Flam, when taken individually or in combination with one another. Claims 7 to 10 and 17 to 20 depend respectively from independent Claims 1 and 11. Claims 7 to 10 and 17 to 20 are therefore patentable for the reasons discussed in conjunction with Claims 1 and 11, and for the additional features recited in these claims;
(2) independent Claims 1 and 11 are directed to statutory subject matter because the claims recite elements that amount to something significantly more than the judicial exception under Step 2B of the Alice test. (See Alice Corp., 134 S. Ct. at 2354, 110 USPQ2d at 1981). Under Step 2B, MPEP Chapter 2106.05 states that ''[e]valuating additional elements to determine whether they amount to an inventive concept requires considering them both individually and in combination to ensure that they amount to significantly more than the judicial exception itself." Consideration of the elements in combination is particularly important, because even if an additional element does not amount to significantly more on its own, it can still amount to significantly more when considered in combination with the other elements of the claim. See BASCOM Global Internet v. AT&T Mobility LLC, 827 F.3d 1341, 1350-51; 119 USPQ2d 1236, 1243 (Fed. Cir. 2016). The Office Action at page 6 concludes that Claims 1 and 11 do not include additional elements that amount to significantly more than a judicial exception. To arrive at this conclusion, the Office Action identifies the additional elements as a computer. The Office Action argues that this additional element is merely linked to an abstract idea. The Office Action also argues that a computer is well-understood, routine, and conventional in nature. The Office Action, contrary to The Advance notice of change to the MPEP, dismisses the additional elements as mere ''generic computer components'' without considering whether such elements confer a technological improvement to a technical problem. Specifically, the Office Action identifies the computer as a generic computer component. The Office Action then concludes that the generic computer component does not confer a technological improvement to a technical problem because it is merely linked to an abstract idea without taking into consideration the features related to automatically populating a data structure with certain insurance benefits data. For the reasons below, the claims recite a technological improvement to a technical problem to ensure a patient record has the correct insurance benefits data;
(3) to BASCOM and Desjardins, Claims 1 to 5, 7 to 15, and 17 to 20 recite an improvement over prior art systems in the field of insurance database management. Mirroring BASCOM and Ex parte Desjardins, the claims of the present application recite a data structure template that has the same predetermined data fields as those stored in a memory device, including medical benefits fields and an insurance provider identifier field. The system creates a patient-specific account data structure using this template, automatically populates the medical benefits fields based on a matching insurance provider identifier. The claimed features go beyond generic data entry or storage by enabling automatic population and verification without manual mapping or input, ensuring consistency and compatibility across data records, and structuring a way to handle variable formats from different insurance systems through a standard data schema, as discussed in paragraphs [0002] to [0005] of Applicant's specification. The use of a templated structure with field-level data matching and automatic population is a non-conventional and specific implementation that improves system efficiency and reduces error regarding the population of at least information indicative of a copay amount, an out-of-pocket maximum amount, and a deductible amount. Further, the claim recites organizing stored data structures in memory by insurance group identification number, which provides a non-generic way of indexing and retrieving benefits data, allows for efficient, group-based querying and filtering, and enables automated population of patient records using matching identifiers. This organizational strategy is not merely conventional data storage but a specific, purpose-built method to solve the real-world technical challenge of non-standardized insurance data formats. Moreover, the claim recites a server that is communicatively coupled to a memory device and a patient information database over a network, capable of automated querying, matching, and storing based on structured identifiers. These claimed features reduce manual verification across disparate systems, automate end-to-end record generation and population using a defined logical sequence, reduce human error and improve reliability in healthcare administration. The coordination of networked components performing specific, interrelated data processing functions is not conventional and reflects an inventive system design tailored to the domain-specific problem. In the present application, each individual component (e.g., server, memory device) and the specific configuration and interaction of these components, including how data is structured, queried, matched, and populated, form a non-generic, non-conventional combination that solves a technical problem in healthcare IT. As emphasized in BASCOM and Ex parte Desjardins, claims that solve a problem rooted in computer technology using a specific arrangement of technological components can constitute an inventive concept. Applicant respectfully submits that the recited subject matter does not merely perform certain features on a generic computer. Similar to Ex parte Desjardins and BASCOM, Claims 1 to 5, 7 to 15, and 17 to 20 of the Subject Application instead are directed to statutory subject matter regarding novel data structures (including templates with matching fields), automated, identifier-based querying and population logic, organized data indexing by insurance group, and interoperability mechanisms across heterogeneous healthcare entities. As such, present Claims 1 to 5, 7 to 15, and 17 to 20 are directed to statutory subject matter by integrating a judicial exception into a practical application such that the claims are not directed to the judicial exception. In view thereof, the 35 U.S.C. § 101 rejection of Claims 1 to 5, 7 to 15, and 17 to 20 should be withdrawn.
In response to argument (1), the Examiner finds the Applicant’s argument(s) persuasive. The Examiner has supplemented the combination of Bose (U.S. Patent Pre-Grant Publication No. 2023/0352154) in view of Wales et al. (U.S. Patent Pre-Grant Publication No. 2020/0234377) with Brekka et al. (U.S. Patent Pre-Grant Publication No. 2019/0114719) to teach “a memory device having a plurality of data structures, wherein the plurality of data structures include predetermined data fields that comprise at least medical benefits data fields and an insurance provider identifier data field, the medical benefits data fields including at least a copay amount data field, an out-of-pocket maximum data field, and a deductible data field, wherein the data structures in the memory device are organized by an insurance group identification number; and after locating a data structure in the memory device with the same insurance provider identifier, automatically record medical benefits data in the medical benefits data fields of the data structure in the memory device into the medical benefits data fields of the patient account data structure so that the patient account data structure includes information indicative of a copay amount, an out-of-pocket maximum amount, and a deductible amount” as described above in the 35 U.S.C. 103 rejection(s) above. The Examiner maintains that the combination of Bose/Wales/Brekka encompasses the newly amended claims as Bose recites in Paragraph [0146]: “Next, as shown in FIG. 11B, the user may review and verify that information populated by the system is accurate. For example, the user may ensure that the provider, insurance, form, letter 1100, and author are all entered appropriately. Typically, the first letter 1100 to be sent out will be Improper Processing Methodology Eligible and shown in selection 1102.” which when combined with Brekka’s teachings of “For the procedure table, this screen is populated with the information related to the selected encounter that a patient may have” in Paragraphs [0056]-[0057]. The 35 U.S.C. 103 rejection(s) stand.
In response to argument (2), the Examiner does not find the Applicant’s argument(s) persuasive. The Examiner maintains that the newly amended claims are directed to an abstract idea without significantly more. Looking at the limitations as an ordered combination adds nothing that is not already present when looking at the elements taken individually. There is no indication that the combination of elements improves the functioning of a computer or improves any other technology. Their collective functions merely provide conventional computer implementation and do not impose a meaningful limit to integrate the abstract idea into a practical application. The claims are not patent eligible. The 35 U.S.C. 101 rejection(s) stand.
In response to argument (3), the Examiner does not find the Applicant’s argument(s) persuasive. The Examiner does not acknowledge that the Applicant’s claimed invention show an improvement in computer-functionality as the Applicant’s claimed invention is similar to “ii. Accelerating a process of analyzing audit log data when the increased speed comes solely from the capabilities of a general-purpose computer, FairWarning IP, LLC v. Iatric Sys., 839 F.3d 1089, 1095, 120 USPQ2d 1293, 1296 (Fed. Cir. 2016)” (See MPEP 2106.05(a)(I)), and the courts have indicated may not be sufficient to show an improvement in computer-functionality. The Examiner does not acknowledge that the Applicant’s newly amended claims are similar to BASCOM as the Applicant’s claims recite a set of instructions for a process to be followed, but do not recite customizable filtering features specific to each end user as any person with access to the claimed invention could search for the same person or people, the end user could then receive the same exact result as another end user. The Examiner does not acknowledge that the Applicant’s newly amended claims are similar to Desjardins as the Applicant’s claims do not recite a trained machine learning model to execute the claimed limitations, only a generic computer server and a memory device. Desjardins addresses improvements to artificial intelligence and machine learning. The 35 U.S.C. 101 rejection(s) stand.
Conclusion
The prior art made of record and not relied upon is considered pertinent to applicant's disclosure.
Tanner, Jr. et al. (U.S. Patent Pre-Grant Publication No. 2017/0220768), describes a system and method provide individuals making decisions for a member, such as what drug to prescribe, insight into a member's pharmacy eligibility, formularies, prescription history, etc. prior to prescribing or dispensing medication. The dynamic distributed pharmacy transactional network processing may combine multiple data feeds to bring pharmacy transactions, transparency, functionality to members, prescribers, pharmacists and employers.
Chmait et al. (U.S. Patent Pre-Grant Publication No. 2016/0071225), describes a method comprises, responsive to a query from a user, retrieving from a database a list of responses comprising one or more health care providers offering one or more health care services at a provider-supplied price; filtering the list of responses based on a geographic location included in the query; providing, for display, the filtered list of responses; receiving a payment from the user for a response selected from the filtered list of responses; automatically sending a notification of the payment to a provider associated with the selected response; and responsive to receiving an order fulfillment notification from the provider, automatically providing the payment to the provider.
Swan (“Emerging Patient-Driven Health Care Models: An Examination of Health Social Networks, Consumer Personalized Medicine and Quantified Self-Tracking”), describes a new class of patient-driven health care services is emerging to supplement and extend traditional health care delivery models and empower patient self-care.
Any inquiry concerning this communication or earlier communications from the examiner should be directed to Bennett S Erickson whose telephone number is (571)270-3690. The examiner can normally be reached Monday - Friday: 9:00am - 5:00pm.
Examiner interviews are available via telephone, in-person, and video conferencing using a USPTO supplied web-based collaboration tool. To schedule an interview, applicant is encouraged to use the USPTO Automated Interview Request (AIR) at http://www.uspto.gov/interviewpractice.
If attempts to reach the examiner by telephone are unsuccessful, the examiner’s supervisor, Robert Morgan can be reached at (571) 272-6773. The fax phone number for the organization where this application or proceeding is assigned is 571-273-8300.
Information regarding the status of published or unpublished applications may be obtained from Patent Center. Unpublished application information in Patent Center is available to registered users. To file and manage patent submissions in Patent Center, visit: https://patentcenter.uspto.gov. Visit https://www.uspto.gov/patents/apply/patent-center for more information about Patent Center and https://www.uspto.gov/patents/docx for information about filing in DOCX format. For additional questions, contact the Electronic Business Center (EBC) at 866-217-9197 (toll-free). If you would like assistance from a USPTO Customer Service Representative, call 800-786-9199 (IN USA OR CANADA) or 571-272-1000.
/Bennett Stephen Erickson/Primary Examiner, Art Unit 3683
Prosecution Insights