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 .
Priority
Acknowledgment is made of Applicant's claim for priority to the following application(s):
* 63516341 filed 28 July 2023
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) 1-19 and 21 is/are rejected under 35 U.S.C. 101 because the claimed invention is directed to abstract idea without significantly more.
Claim 1 recites:
A computer-implemented method for adaptive determination of healthcare claim integrity, the method comprising operating at least one processor to:
receive a healthcare claim request from a computing device, the healthcare claim request comprising initial healthcare claim request data;
apply the initial healthcare claim request data to at least one claim integrity model to predict an initial integrity of the healthcare claim request; and
in response to the initial integrity prediction being indicative that the healthcare claim request lacks integrity,
automatically generate one or more supplementary data requests for one or more supplementary documents associated with the healthcare claim request;
transmit the one or more supplementary data requests to corresponding computing devices associated with the one or more supplementary documents;
receive at least one supplementary document of the one or more supplementary documents;
extract supplementary healthcare claim data from the at least one supplementary documents received;
apply the initial healthcare claim data and supplementary healthcare claim data to the at least one claim integrity model to generate a subsequent integrity indicator; and
transmit the subsequent integrity indicator to the computing device for display;
otherwise, transmit the initial integrity indicator to the computing device for display.
Step 1:
The claim as a whole falls within at least one statutory category, i.e. a process, machine, manufacture, or composition of matter.
Step 2A Prong One:
The highlighted portion, as drafted, is a process that, under its broadest reasonable interpretation, falls under “Certain methods of organizing human activity” because the steps of processing a claim are traditionally performed by a human being, i.e. fundamental economic principles or practices (including hedging, insurance, mitigating risk); commercial or legal interactions (including agreements in the form of contracts; legal obligations; advertising, marketing or sales activities or behaviors; business relations); managing personal behavior or relationships or interactions between people (including social activities, teaching, and following rules or instructions). MPEP 2106.04(a)(2)(II)
The highlighted portion, as drafted, is a process that, under its broadest reasonable interpretation, falls under “Mental processes”.
But for a generic computer recited with a high level of generality in a post hoc manner to implement the abstract idea, the steps of processing a claim may be performed in the human mind either mentally or with pen and paper.
Accordingly, these limitations have been found to be directed towards concepts performed in the human mind (including an observation, evaluation, judgment, opinion). MPEP 2106.04(a)(2)(III)
The different categories of abstract ideas are being considered together as one single abstract idea. MPEP 2106.04(II)(B)
Dependent claim(s) recite(s) additional subject matter which further narrows or defines the abstract idea embodied in the claims (such as claim(s) 2-17 reciting limitations further defining the abstract idea, which may be performed in the mind but for recitation of generic computer components, and/or may be a method of managing relationship or interactions between people).
Step 2A Prong Two:
This judicial exception is not integrated into a practical application. In particular, the claim recites the following additional element(s), if any:
the method comprising operating at least one processor to:
receive a healthcare claim request from a computing device, the healthcare claim request comprising initial healthcare claim request data;
at least one claim integrity model;
transmit the one or more supplementary data requests to corresponding computing devices associated with the one or more supplementary documents;
receive at least one supplementary document of the one or more supplementary documents; and
transmit the subsequent integrity indicator to the computing device for display;
otherwise, transmit the initial integrity indicator to the computing device for display.
The additional element(s) do(es) not integrate the abstract idea into a practical application, other than the abstract idea per se.
Regarding the processor, the Specification as originally filed on 28 July 2023 in parent application 63516341 (hereafter referred to as “the Provisional Specification”) discloses that the processor may be any type of processor, including a generic processor (page 5 paragraph 0022).
Similarly, regarding the computing device, the Provisional Specification discloses any generic computing device (page 6 paragraph 0027-0028).
Regarding the model, the Provisional Specification discloses any machine learning, i.e. a generic computer (page 7-8 paragraph 0035).
Accordingly, these limitations amount(s) to mere instructions to apply an exception (invoking computers as a tool to perform the abstract idea). MPEP 2106.05(f))
The steps of sending and receiving data merely add(s) insignificant extra-solution activity to the abstract idea (mere data gathering, selecting a particular data source or type of data to be manipulated, insignificant application). MPEP 2106.05(g))
The limitations “for display” represent the intended use of the received data, and do not positively limit the claim to a particular step. Therefore, the limitations generally link(s) the abstract idea to a particular technological environment or field of use. MPEP 2106.05(h))
Dependent claim(s) recite(s) additional subject matter which amount to limitation(s) consistent with the additional element(s) in the independent claims (such as claim(s) 6 reciting AI, additional limitation(s) which amount(s) to invoking computers as a tool to perform the abstract idea; claim 7 reciting NLP, claim 8 reciting OCR, additional limitation(s) which add(s) insignificant extra-solution activity to the abstract idea by selecting a particular data source or type of data to be manipulated).
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.
Accordingly, the additional elements do not integrate the judicial exception into a practical application because it does not impose any meaningful limits on practicing the abstract idea.
Accordingly, the claim recites 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, the additional elements amount to no more than mere instructions to apply an exception, add insignificant extra-solution activity to the abstract idea, and/or generally link the abstract idea to a particular technological environment or field of use.
The additional elements, as discussed above and incorporated herein, amount to no more than mere instructions to apply an exception, add insignificant extra-solution activity to the abstract idea, and/or generally link the abstract idea to a particular technological environment or field of use, as discussed above and incorporated herein.
Mere instructions to apply an exception, insignificant extra-solution activity, and linking to a particular technological environment using a generic computer component cannot provide an inventive concept.
Regarding the steps of sending and receiving data, these limitations amount(s) to element(s) that have been recognized as well-understood, routine, and conventional activity in particular fields (e.g., receiving or transmitting data over a network, Symantec, MPEP 2106.05(d)(II)(i)). MPEP 2106.05(d)(II)(ii))
Dependent claims recite additional subject matter which amount to limitations consistent with the additional elements in the independent claims (such as claim(s) 7 reciting NLP, claim 8 reciting OCR; Official Notice is taken that NLP and OCR are old and well-known in the art of document processing). MPEP 2106.05(d)(II)(ii))
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.
The claim is not patent eligible.
Claim(s) 18-19, 21 recite(s) substantially similar limitations as those of claim(s) 1-2 above, and are therefore rejected for substantially similar rationale as applied above, and incorporated herein.
Claim Rejections - 35 USC § 102
The following is a quotation of the appropriate paragraphs of 35 U.S.C. 102 that form the basis for the rejections under this section made in this Office action:
A person shall be entitled to a patent unless –
(a)(1) the claimed invention was patented, described in a printed publication, or in public use, on sale, or otherwise available to the public before the effective filing date of the claimed invention.
(a)(2) the claimed invention was described in a patent issued under section 151, or in an application for patent published or deemed published under section 122(b), in which the patent or application, as the case may be, names another inventor and was effectively filed before the effective filing date of the claimed invention.
Claim(s) 1-5, 18-19, 21 is/are rejected under 35 U.S.C. 102(a)(1) and (a)(2) as being anticipated by Gelber (20030069760).
Claim 1: Gelber discloses:
A computer-implemented (Figure 3 illustrating a computer) method (Abstract illustrating a method) for adaptive (Abstract illustrating that the method is based on rules [considered to be a form of “adaptive”) determination of healthcare claim integrity (Abstract illustrating processing a claim according to rules [considered to be a form of “integrity”), the method comprising operating at least one processor to:
receive a healthcare claim request from a computing device, the healthcare claim request comprising initial healthcare claim request data (Figure 1 label 14 illustrating receiving a claim for health care services);
apply the initial healthcare claim request data to at least one claim integrity model to predict an initial integrity of the healthcare claim request (Figure 1 label 16 illustrating using a computer to adjudicate a claim [considered to be a form of “initial integrity”]); and
in response to the initial integrity prediction being indicative that the healthcare claim request lacks integrity (Figure 1 label 18 illustrating determining that the claim deserves non-payment [considered to be a form of “lack integrity”]),
automatically generate one or more supplementary data requests for one or more supplementary documents associated with the healthcare claim request (Figure 1 label 18 illustrating generating a reason code requiring additional data);
transmit the one or more supplementary data requests to corresponding computing devices associated with the one or more supplementary documents (Figure 1 label 20 illustrating sending the rejected claim to the provider’s computer for additional support);
receive at least one supplementary document of the one or more supplementary documents (Figure 1 label 22 illustrating receiving a corrected claim with supporting documents);
extract supplementary healthcare claim data from the at least one supplementary documents received (Figure 1 label 22 illustrating reprocessing the corrected claim);
apply the initial healthcare claim data and supplementary healthcare claim data to the at least one claim integrity model to generate a subsequent integrity indicator (Figure 1 label 22 illustrating readjudicating the claim based on the additionally available documents); and
transmit the subsequent integrity indicator to the computing device for display (Figure 1 label 22 illustrating providing the claim for further display and processing);
otherwise, transmit the initial integrity indicator to the computing device for display (Figure 1 label 18 illustrating providing assigned payment for the claim).
Claim 2: Gelber discloses:
The computer-implemented method of claim 1, as discussed above and incorporated herein.
Gelber further discloses:
comprises operating the at least one processor to:
receive a second supplementary document after transmitting a first subsequent integrity indicator to the computing device for display, the first subsequent integrity indicator being based on the initial healthcare claim data and supplementary healthcare claim data from a first supplementary document (Figure 1 illustrating resubmitting the claim repeatedly until the claim is approved);
re-apply the initial healthcare claim data and supplementary healthcare claim data from the first supplementary document and the second supplementary document to the at least one claim integrity model to generate a second subsequent integrity indicator (Figure 1 label 18 illustrating reprocessing the claim with the newly submitted supporting documents);
compare the second subsequent integrity indicator with the first subsequent integrity indicator (page 4 paragraph 0053 illustrating comparing the claim’s codes) and
in response to determining that the second subsequent integrity indicator is different from the first subsequent integrity indicator, transmit the second subsequent integrity indicator to the computing device for display (page 4 paragraph 0053 illustrating transmitting the claim approval).
Claim 3: Gelber discloses:
The computer-implemented method of claim 1, as discussed above and incorporated herein.
Gelber further discloses:
comprises operating the at least one processor to:
apply the initial healthcare claim request data to a first claim integrity model to predict the initial integrity of the healthcare claim request (Figure 1 label 16-18 illustrating adjudicating the claim); and
apply the initial healthcare claim data and supplementary healthcare claim data to a second claim integrity model to generate the subsequent integrity indicator (page 1 paragraph 0012 illustrating using new rules to process the claim).
Claim 4: Gelber discloses:
The computer-implemented method of claim 1, as discussed above and incorporated herein.
Gelber further discloses:
wherein the healthcare claim request comprises a pre-authorization request (page 6 paragraph 0072 illustrating preauthorization data).
Claim 5: Gelber discloses:
The computer-implemented method of claim 1, as discussed above and incorporated herein.
Gelber further discloses:
wherein the initial integrity of the healthcare claim request is binary (Figure 1 label 18 illustrating payment or nonpayment).
Claim(s) 18-19, 21 recite(s) substantially similar limitations as those of claim(s) 1-2, 4 above, and are therefore rejected for substantially similar rationale as applied above, and incorporated herein.
Claim Rejections - 35 USC § 103
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.
Claim(s) 6-16 is/are rejected under 35 U.S.C. 103 as being unpatentable over Gelber in view of Khan (20230316408).
Claim 6: Gelber discloses:
The computer-implemented method of claim 1, as discussed above and incorporated herein.
Gelber further discloses:
comprises operating the at least one processor t
Gelber does not disclose:
to apply a generative artificial intelligence (AI) model.
Khan discloses:
to apply a generative artificial intelligence (AI) model (page 10 paragraph 0081 illustrating using AI to generate a request for additional documents).
Before the effective filing date of the claimed invention, it would have been obvious to one of ordinary skill in the art to include the AI of Khan within the claim adjudication system of Gelber with the motivation of improving patient care by leveraging existing AI techniques to reduce the cost of claims processing (Khan; page 1 paragraph 0001).
Claim 7: Gelber in view of Khan disclose:
The computer-implemented method of claim 6, as discussed above and incorporated herein.
Gelber further discloses:
comprises operating the at least one processor to
Gelber does not disclose:
apply natural language processing.
Khan discloses:
apply natural language processing (page 2 paragraph 0013 illustrating using NLP to extract data from the claim).
Before the effective filing date of the claimed invention, it would have been obvious to one of ordinary skill in the art to include the AI of Khan within the claim adjudication system of Gelber in view of Khan with the motivation of improving patient care by leveraging existing AI techniques to reduce the cost of claims processing (Khan; page 1 paragraph 0001).
Claim 8: Gelber in view of Khan disclose:
The computer-implemented method of claim 7, as discussed above and incorporated herein.
Gelber does not disclose:
further comprises operating the at least one processor to apply optical character recognition to extract the supplementary healthcare claim data from the at least one supplementary documents received.
Khan discloses:
further comprises operating the at least one processor to apply optical character recognition to extract the supplementary healthcare claim data from the at least one supplementary documents received (page 13 paragraph 0110 illustrating using OCR to process the claim documents).
Before the effective filing date of the claimed invention, it would have been obvious to one of ordinary skill in the art to include the AI of Khan within the claim adjudication system of Gelber in view of Khan with the motivation of improving patient care by leveraging existing AI techniques to reduce the cost of claims processing (Khan; page 1 paragraph 0001).
Claim 9: Gelber in view of Khan disclose:
The computer-implemented method of claim 8, as discussed above and incorporated herein.
Gelber further discloses:
comprises operating the at least one processor to:
receive a health record of a patient associated with the healthcare claim request (page 4-5 paragraph 0056 illustrating receiving the patient’s record); and
extract one or more health elements from the health record, each of the one or more health elements corresponding to demographic information (page 4-5 paragraph 0056 illustrating the patient’s demographics), healthcare provider information, facility information, a symptom, a condition, a diagnosis, a procedure, a treatment, a medication, or an incident experienced by the patient (these limitations are rendered optional by the limitation “one or more” and therefore need not be disclosed by the applied art).
Claim 10: Gelber in view of Khan disclose:
The computer-implemented method of claim 6, as discussed above and incorporated herein.
Gelber further discloses:
comprises operating the at least one processor to:
receive an invoice corresponding to the healthcare claim request (page 1 paragraph 5 illustrating the claim comprising an identification of the services rendered to the patient and financial information);
extract one or more invoiced items from the invoice, each of the one or more invoiced items having a claim code corresponding to a procedure, a treatment, or a service provided to the patient (Figure 1 label 16 illustrating extracting a payment code for the claim);
and for each invoiced item of the one or more invoiced items, compare the invoiced item to the one or more health elements of the health record (Figure 1 label 16 illustrating adjudicating the claim based on the patient’s record); and generate an item integrity indicator for the invoiced item at least based on the comparison of the invoiced item to the one or more health elements (Figure 1 label 18 illustrating adjudicating the claim based on the billed procedures).
Claim 11: Gelber in view of Khan disclose:
The computer-implemented method of claim 10, as discussed above and incorporated herein.
Gelber further discloses:
comprises operating the at least one processor to, in response to determining that none of the one or more health elements are associated with the invoiced item, generate the item integrity indicator as being indicative of a lack of integrity (page 1 paragraph 0009 illustrating rejecting a claim for missing patient data).
Claim 12: Gelber in view of Khan disclose:
The computer-implemented method of claim 10, as discussed above and incorporated herein.
Gelber further discloses:
comprises operating the at least one processor to:
receive a policy document associated with the healthcare claim request (page 5 paragraph 0057 illustrating receiving a policy code);
extract one or more policy elements from the policy document, each policy element comprising one or more rules related to one or more claim codes, each rule of the one or more rules being either a permissive rule or a restrictive rule (page 5 paragraph 0057 illustrating determining policy rules);
for each invoiced item of the one or more invoiced items, compare the claim code of the invoiced item to at least one rule that is related to the claim code of the invoiced item (page 5 paragraph 0057 illustrating adjudicating the claim based on the policy rules); and
generate the item integrity indicator for the invoiced item at least based on the comparison of the invoiced item to the at least one rules (page 5 paragraph 0057 illustrating adjudicating the claim based on the policy rules).
Claim 13: Gelber in view of Khan disclose:
The computer-implemented method of claim 12, as discussed above and incorporated herein.
Gelber further discloses:
comprises operating the at least one processor to:
in response to determining that the claim code complies with one or more restrictive rules related to the claim code, generate the item integrity indicator as being indicative of a lack of integrity (page 5 paragraph 0057 illustrating rejecting the claim if the claim does not comply with a policy rule); and
in response to determining that the claim code does not comply with any restrictive rules related to the claim code and determining that the claim code complies with one or more permissive rules related to the claim code, generate the item integrity indicator as being indicative of a sufficient integrity (page 5 paragraph 0057 illustrating approving the claim if the claim complies with a policy rule).
Claim 14: Gelber in view of Khan disclose:
The computer-implemented method of claim 10, as discussed above and incorporated herein.
Gelber further discloses:
wherein the item integrity indicator for each invoiced item of the one or more invoiced items is binary (Figure 1 label 18 illustrating payment or nonpayment).
Claim 15: Gelber in view of Khan disclose:
The computer-implemented method of claim 14, as discussed above and incorporated herein.
Gelber further discloses:
comprises operating the at least one processor to generate the subsequent integrity indicator based on the item integrity of each of the one or more invoiced items of the invoice (Figure 1 label 18 illustrating rejecting or approving the claim based on the adjudication decision).
Claim 16: Gelber discloses:
The computer-implemented method of claim 1, as discussed above and incorporated herein.
Gelber does not disclose:
comprises operating the at least one processor to train the at least one claim integrity model using the initial integrity prediction, the subsequent integrity indicator, the initial healthcare claim data, and the supplementary healthcare claim data.
Khan discloses:
comprises operating the at least one processor to train the at least one claim integrity model using the initial integrity prediction, the subsequent integrity indicator, the initial healthcare claim data, and the supplementary healthcare claim data (page 2 paragraph 0012 illustrating training the AI using past claims data).
Before the effective filing date of the claimed invention, it would have been obvious to one of ordinary skill in the art to include the AI of Khan within the claim adjudication system of Gelber with the motivation of improving patient care by leveraging existing AI techniques to reduce the cost of claims processing (Khan; page 1 paragraph 0001).
Claim(s) 17 is/are rejected under 35 U.S.C. 103 as being unpatentable over Gelber in view of Johnson (5664109).
Claim 17: Gelber discloses:
The computer-implemented method of claim 1, as discussed above and incorporated herein.
Gelber further discloses:
comprises operating the at least one processor to:
generate a summary of the at least one supplementary document, the summary comprising at least a portion of the supplementary healthcare claim data extracted from the at least one supplementary document (as discussed above and incorporated herein)
transmit the summary of the at least one supplementary document with the subsequent integrity indicator to the computing device for display (Figure 1 label 18 illustrating transmitting the claim for processing and further review).
Gelber does not disclose:
generate one or more pointers, each pointer being associated with a portion of the at least one supplementary document;
at least one pointer related to the supplementary healthcare claim data, the at least one pointer related to the supplementary healthcare claim data being one of the one or more pointers of the at least one supplementary document.
Johnson discloses:
generate one or more pointers, each pointer being associated with a portion of the at least one supplementary document (column 7 line 50-57 illustrating generating a pointer to the document for the patient);
at least one pointer related to the supplementary healthcare claim data, the at least one pointer related to the supplementary healthcare claim data being one of the one or more pointers of the at least one supplementary document (column 7 line 50-57 illustrating generating a pointer to the document for the patient).
Before the effective filing date of the claimed invention, it would have been obvious to one of ordinary skill in the art to include the pointer of Johnson within the claim adjudication system of Gelber with the motivation of improving patient care by leveraging existing patient record processing (Johnson; column 7 line 50-57).
Conclusion
The prior art made of record and not relied upon is considered pertinent to applicant's disclosure.
Scarasso (20140122098) discloses appraising medical services for financial reimbursement (Abstract) in a manner similar to those disclosed in the instant pending Specification as originally filed.
Kosatka-Pioro (20150269684) discloses determining financial compensation for a medical service (Abstract) in a manner similar to those disclosed in the instant pending Specification as originally filed.
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/T.N.N./ Examiner, Art Unit 3685
/KAMBIZ ABDI/ Supervisory Patent Examiner, Art Unit 3685
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