DETAILED ACTION
This communication is in response to Application No. 18/884,531 filed on 9/13/2024. The amendment presented on 1/12/2026, which cancels claim 6, amends claims 1, 13, and 20, and adds new claim 21, is hereby acknowledged. Claims 1-5, 8-16, and 18-21 have been examined.
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and the fee set forth in 37 CFR 1.17(e) has been timely paid, the finality of the previous Office action has been withdrawn pursuant to 37 CFR 1.114.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 1/12/2026 has been entered.
Information Disclosure Statement
The information disclosure statement (IDS) submitted on 1/12/2026 is being considered by the examiner.
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.
Claims 1-5, 11-16, and 20-21 are rejected under 35 U.S.C. 103 as being unpatentable over Niemeyer (US 2019/0318431) in view of DeGasperis (US 2017/0351824).
Regarding claims 1, 13, and 20, Niemeyer teaches as follows:
a system (interpreted as the server 112 in figure 1) for coordinating data exchange among a plurality of devices (the server 112 provides instances of the episode eligibility system 120 and the claim adjudication system 122 to other entities such as the healthcare facility 108, healthcare service providers 114 and the insurance service provider 116, see, ¶ [0042] and figure 1), the system comprising:
a processing system that includes one or more processors (processor 1006 in figure 10) and one or more memories (memory 1008 in figure 10) coupled with the one or more processors (the server 1000 includes a computer system 1002 and one or more databases. The computer system 1002 includes a processor 1006 for executing instructions. Instructions may be stored in, for example, but not limited to, a memory 1008, see, ¶ [0133]-[0134] and figure 10), the processing system configured to:
receive, from a service server, first verification data and a request (at operation 256, the healthcare service provider 114 submits the claims for the healthcare services to the server 112, see, ¶ [0058] and figure 2B), the first verification data associated with performance of the service (each claim is associated with one or more health care services availed by the patient in the predefined time for the clinical episode using the episode card, see, ¶ [0007] and the operation 806 in figure 8, see, ¶ [0124]) and the request including a request for payment for performance of the service (at operation 262, the episode underwriter 124 processes the claim payment request. The claim payment request comprises payment amount for the healthcare service availed by the patient 102. At operation 264, the episode underwriter 124 transfers the payment amount to the healthcare service providers 114, see, ¶ [0061] and figure 2B)(therefore, the claim received from the healthcare service providers inherently include requested payment amount associated with health care services providing for the patient);
verifying, based on the first verification data, that at least a portion of the service has been completed (at operation 258, the server 112 may determine the validity of the claims submitted by the healthcare service provider 114 by classifying each claim as a valid claim or an invalid claim based on the episode definition parameters stored in a database of the server 112. For instance, the claims raised by each of the healthcare service providers for each service availed by the patient 102 is compared against the episode definition parameters of the clinical episode as determined by the episode management platform 118 to determine healthcare services that are covered by the bundled payment for the clinical episode, see, ¶ [0059] and figure 2B)(the healthcare services are all completed before submitting claims. Therefore, Niemeyer teaches the limitation of the at least a portion of the service has been completed);
determining, in response to determining that at least the portion of the service has been completed and based on the first verification data, claim information for a payer associated with payment for performance of the service (at operation 258, the server 112 may determine the validity of the claims submitted by the healthcare service provider 114 by classifying each claim as a valid claim or an invalid claim based on the episode definition parameters stored in a database of the server 112, see, ¶ [0059] and figure 2B); and
send the claim information to a client server associated with the payer (at operation 212, the server 112 submits a total bundled claim on behalf of the patient to the insurance service provider 116 (equivalent to applicant’s client server associated with the payer). The total bundled claim is determined by the server based on the clinical episode of the patient and submitted to the insurance service provider after verifying the patient eligibility for bundled payment of the clinical episode, see, ¶ [0051] and figure 2A).
Niemeyer does not explicitly teach of communicating claim acknowlegement between the client serve and the service server.
DeGasperis teaches as follows:
The payer (equivalent to applicant’s client server) transmits a claim acknowledgment, preferably an ANSI 277 CA claim-acknowledgement response to the computer system, indicating its acceptance or rejection of the invoice and supporting documents. The computer system converts the claim acknowledgment response into human readable terminology and transmits the converted claim acknowledgement back to the healthcare provider (equivalent to applicant’s service server) that provided the original invoice. (see, ¶ [0224]-[0225]).
Therefore, it would have been obvious for one of ordinary skill in the art before the effective filing date of the claimed invention to modify Niemeyer with DeGasperis to include the well-known claim acknowledgement (ANSI 277 CA) as taught by DeGasperis in order to efficiently communicate between the healthcare provider and the insurance company.
Regarding claims 2 and 14, Niemeyer teaches as follows:
receiving, from the client server, payment information, wherein the payment information indicates that payment has been processed for performance of the service; and sending, to the service server, the payment information (at operation 262, the episode underwriter 124 (equivalent to applicant’s client server) processes the claim payment request. The claim payment request comprises payment amount for the healthcare service availed by the patient 102. At operation 264, the episode underwriter 124 transfers the payment amount to the healthcare service providers 114 (equivalent to applicant’s service server), see, ¶ [0061] and figure 2B).
Regarding claims 3 and 15, Niemeyer teaches all limitations as presented above except for receiving the well-known acknowledgment.
DeGasperis teaches acknowledgements or responses received in response to those claims (see, ¶ [0046]) as presented above.
Therefore, they are rejected for similar reason as presented above.
Regarding claim 4, Niemeyer teaches as follows:
the episode card provides allowed heath care services from the healthcare service providers (the episode card may allow the patient 102 to avail health care services from the healthcare service providers 114 for a predefined time. The episode card includes claim submission information for the healthcare services availed by the patient from the one or more healthcare service providers, see, ¶ [0052] and 214 in figure 2A).
Niemeyer in view of DeGasperis does not explicitly teach of using the identifier for the service.
Therefore, it would have been obvious for one of ordinary skill in the art before the effective filing date of the claimed invention to modify Niemeyer in view of DeGasperis to include service identifiers in order to efficiently identify each care service.
Regarding claim 5, Niemeyer teaches as follows:
wherein the claim information comprises a service identifier for the service, one or more dates of performance of the service, one or more durations of performance of the service, one or more billing units for the service, a payer format associated with the payer, an identifier of a provider of the service, an identifier of a client of the service, or a combination thereof (the episode card may allow the patient 102 to avail health care services from the healthcare service providers 114 for a predefined time. The episode card includes claim submission information for the healthcare services availed by the patient from the one or more healthcare service providers. The claim submission information helps in proper adjudication of claims through the claim adjudication system 122. In an embodiment, the episode card includes patient information (patient name, member ID, group ID and plan ID), clinical episode for which the episode card is valid, the claim submission information and one or more terms and conditions for the bundled payment of claims, see, ¶ [0052]).
Regarding claim 11, Niemeyer does not explicitly teach the real time communications.
DeGasperis teaches as follows:
The present invention provides healthcare providers with real time regarding which healthcare service will be reimbursed and when by identifying the patient, identifying said patient's healthcare service requirements, processing said patient's payer's forms for said patient's healthcare service requirements on a prospective basis; and communicating said patient's reimbursable patient's healthcare (see, ¶ [0049]).
Therefore, it would have been obvious for one of ordinary skill in the art before the effective filing date of the claimed invention to modify Niemeyer with DeGasperis to include the real time communications as taught by DeGasperis in order to quickly process urgent healthcare claims.
Regarding claim 16, Niemeyer teaches as follows:
wherein determining the claim information comprises determining a number of authorized units (interpreted as the list of healthcare providers) of the service have been performed based on the first verification data (the patient 102 may undergo a knee replacement surgery at a hospital facility X and physiotherapy sessions with a service provider Y using the episode card. It shall be noted that the hospital facility X and the service provider Y are healthcare service providers pursuant to the episode card's list of healthcare providers providing valid procedures that cover the clinical episode of knee replacement, see, ¶ [0056] and figure 2B).
Regarding claim 12, Niemeyer teaches as follows:
wherein the first verification data includes verification for a plurality of services (see, rejection in response to claim 4), and wherein determining the claim information includes determining separate claim information for each of the plurality of services (the claims are submitted by the healthcare service provider 114 to the claim adjudication system 122 for validating the claims. In cases where the patient 102 avails services from different hospital facilities and/or healthcare service providers, the claims of each hospital facilities and/or healthcare service providers are submitted to the claim adjudication system 122, see, ¶ [0058]).
Regarding claim 21, Niemeyer does not explicitly teach the claim acknowledgement but DeGasperis teaches as follows:
The payer (equivalent to applicant’s client server) transmits a claim acknowledgment, preferably an ANSI 277 CA claim-acknowledgement response to the computer system, indicating its acceptance or rejection of the invoice and supporting documents (see, ¶ [0224]), which is equivalent to applicant’s acknowledgment indicating status of a claim associated with the claim information.
Therefore, it is rejected for similar reason as presented above.
Claims 8-10 and 18-19 are rejected under 35 U.S.C. 103 as being unpatentable over Niemeyer (US 2019/0318431) in view of DeGasperis (US 2017/0351824), and further in view of Marvin et al. (hereinafter Marvin)(US 2005/0288972).
Regarding claims 8-10 and 18-19, Niemeyer in view of DeGasperis all limitations except for converting formatting or encoding between two entities.
Marvin teaches as follows:
healthcare service providers spend a large quantity of time and effort communicating administrative transactions with health insurance companies. These transactions can include claim submission, member eligibility verification, claim status checks, coordination of benefits with third party payers, remittance advice for final disposition of claims, and notification of payments (see, ¶ [0006]); and
the payer gateway 144 may also execute the translation program 630 to convert received claim files to a format expected by any back end processing system 602-608. In that regard, the translation program 630 may access translation data or translation rules 638. The translation rules 638 may specify the steps to be taken or conversions to be executed by the translation program 630 to convert one file format to another file format (see, ¶ [0067] and figures 1 and 6).
Therefore, it would have been obvious for one of ordinary skill in the art before the effective filing date of the claimed invention to modify Niemeyer in view of DeGasperis with Marvin to include the translation program executing on the payer gateway as taught by Marvin in order to efficiently convert claim files between any communicating entities.
Response to Arguments
Applicant’s arguments with respect to claims 1-5, 8-16, and 18-21 have been considered but are moot because the new ground of rejection does not rely on any reference applied in the prior rejection of record for any teaching or matter specifically challenged in the argument.
Conclusion
Any inquiry concerning this communication or earlier communications from the examiner should be directed to Jeong S Park whose telephone number is (571)270-1597. The examiner can normally be reached Monday through Friday 8:00-4:30 ET.
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/JEONG S PARK/Primary Examiner, Art Unit 2454
January 24, 2026