DETAILED ACTION
Acknowledgements
This office action is in response to the claims filed December 13, 2024.
Claims 1-20 are pending.
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 .
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.
Claims 1-20 are rejected to under 35 U.S.C 101 as not being directed to eligible subject matter based on the grounds set out in detail below:
Independent Claims 1 and 18:
Eligibility Step 1 (does the subject matter fall within a statutory category?):
Independent claim 1 falls within the statutory category of method
Independent claim 18 falls within the statutory category of machine
Eligibility Step 2A-1 (does the claim recite an abstract idea, law of nature, or natural phenomenon?): Independent claims 1 and 18 (claim 1 being representative) claimed invention is directed to an abstract idea without significantly more.
The claim elements which set forth the abstract idea in the independent claims (claim 1 being representative) is:
A method for processing an audit of at least one medication prescription, comprising:
receiving, , an audit request comprising an indication of the at least one medication prescription being audited;
identifying, one or more documents, wherein the one or more documents are associated with the at least one medication prescription being audited;
retrieving, , the one or more documents;
and generating, , an audit document related to the at least one medication prescription being audited, wherein the audit document comprises the one or more documents and data associated with the at least one medication prescription being audited
This abstract idea is “certain methods of organizing human activity” as it is following rules and instructions to process an audit of a medication prescription (MPEP § 2106.04(a)(2), subsection II)
Eligibility Step 2A-2 (does the claim recite additional elements that integrate the judicial exception into a practical application?): For Independent claims 1 and 18 judicial exception is not integrated into a practical application.
In Claim 1 and 18 the additional elements are:
a processor
a database
a user interface
Examiner takes the applicable considerations stated in MPEP 2106.04 (d) and analyzes them below in light of the instant applications disclosure and claim elements as a whole.
The additional element, a processor, is performing the abstract idea and stated as general purpose computer tools or equivalent to apply the abstract idea as “apply-it”
The additional element, a database, is applied as “apply-it” as a tool or equivalent to gather data
The additional element, a user interface, is applied as “apply-it” as a tool or equivalent to display data
Accordingly, claims 1 and 18 do not integrate the abstract idea into a practical application.
Eligibility Step 2B (Does the claim amount to significantly more?): The independent claims do not include additional element which provide significantly more for the same reasons given in prong 2A-2 above. The claims are patent ineligible.
Dependent Claims 2-17 and 19-20:
Eligibility Step 1 (does the subject matter fall within a statutory category?):The dependent claims 2-17 fall within the statutory category of method. The dependent claims 19-20 fall within the statutory category of machine.
Eligibility Step 2A-1 (does the claim recite an abstract idea, law of nature, or natural phenomenon?): Dependent claims 2-17 and 19-20 claimed invention is directed to an abstract idea without significantly more. The claims continue to limit the independent claim 1 and 18 abstract idea by (1) further limiting the types of data and user input and (2) further limiting verifying accuracy of the audit document, (3) the appeal of the document, and (4) risk of audit information. Therefore, the dependent claims inherit the same abstract idea which is This abstract idea is “certain methods of organizing human activity” as it is following rules and instructions to process an audit of a medication prescription (MPEP § 2106.04(a)(2), subsection II)
Eligibility Step 2A-2 (does the claim recite additional elements that integrate the judicial exception into a practical application?): For claims 2-17 and 19-20 this judicial exception is not integrated into a practical application.
In the dependent claims the additional elements not already recited in the independent claims are:
a pharmacy benefit manager server
an artificial intelligence algorithm
Examiner takes the applicable considerations stated in MPEP 2106.04 (d) and analyzes them below in light of the instant applications disclosure and claim elements as a whole.
The additional element, a pharmacy benefit manager server, is is applied as “apply-it” as a tool or equivalent to gather data
The additional element, an artificial intelligence algorithm, is applied as “apply-it” as a tool or equivalent to analyze data
Accordingly, the dependent claims as a whole do not integrate the recited abstract idea into a practical application (MPEP 2106.05(f) and 2106.04(d)(1).
Eligibility Step 2B (Does the claim amount to significantly more?): The dependent claims do not include additional element which provide significantly more for the same reasons given in prong 2A-2 above. The claims are patent ineligible.
Claim Rejections - 35 USC § 102
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 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.
Claims 1-8, 10, 11, and 18-20 are rejected under 35 U.S.C. 102(a)(2) as being anticipated by Rowe III et. al (hereinafter Rowe) (US8489411B1)
As per claim 1, Rowe teaches:
A method for processing an audit of at least one medication prescription, comprising: (Col. 1 lines 19-21 discloses, “This invention relates to the processing and reimbursement of insurance claims. More specifically, it relates to the monitoring and auditing of reimbursed prescription claims in the pharmaceutical industry.”)
receiving, at a processor, an audit request comprising an indication of the at least one medication prescription being audited; (Col. 6 lines 45-51 discloses, “The auditing process of example embodiments of the invention may be conducted periodically or as requested. In alternative embodiments of the invention, the auditing process may occur for each transaction in real-time or near real-time upon receipt of the adjudicated claim by the spread auditing module 123.” And see Col. 7 lines 15-19 discloses, “Similarly, the host server 104 may be any processor-driven 15 device that is configured for receiving and fulfilling requests related to prescription claim transactions. The host server 104 may therefore include a processor 126, a memory 128, input/ output (“I/O”) interface(s) 130 and a network interface 132.” / examiner notes the prescription claim necessarily has indication of the at least one medical prescription when audited)
identifying, using the processor, one or more documents in a database in communication with the processor, wherein the one or more documents are associated with the at least one medication prescription being audited; retrieving, from the database to the processor, the one or more documents; (see Col. 8 lines 19-30 and 34-40 discloses, “As shown in the example embodiment of FIG. 2, the process starts at step 202 where an adjudicated claim previously received at a host server and stored in a database associated with the host server is retrieved (or imported) to undergo the spread auditing process. In an example embodiment of the invention, a customers (e.g., pharmacy) initial reimbursement claim(s), having been adjudicated by a PBM (e.g., insurance processor or group of insurance processors), and may be stored (or identified) in a spread evaluation table located in one or more databases associated with the spread auditing module…[…]… At the host server, the spread auditing module may parse the relevant data to be utilized in the auditing process. For example, the prescription information (e.g., drug name, quantity, date fulfilled, etc.) may be extracted from the previously adjudicated claim. The specific amount (or cost) reimbursed by the PBM for that particular transaction may also be extracted from the adjudicated claim.” / examiner notes the spread evaluation table and adjudicated claims for example are documents which necessarily are associated with a medication prescription)
and generating, using the processor, an audit document related to the at least one medication prescription being audited, wherein the audit document comprises the one or more documents and data associated with the at least one medication prescription being audited. (Col. 6 lines 22-39 discloses, “The spread auditing module 123 may determine if the claim contains the appropriate spread value based on the contractual obligations of the adjudicator (e.g., the PBM 107 and/or the payer system 108). If it is determined that the adjudicated claim does have the appropriate spread value then Such a detection is noted and the transaction is logged and/or indicated to the pharmacy Submitting the reimbursement claim. If the adjudicated claim does not have the appropriate spread value then that adjudicated claim is flagged indicating that further explanation by the adjudicating body is required, and the claim is logged and reported to the responsible adjudicating body for response (e.g., explanation and/or corrective action) and/or reported to a third party (e.g., a payer system that the adjudicating PBM represents, the pharmacy that submitted the reimbursement claim, etc.). The audited results may also be made available via a user interface Such as through a web browser with a password log-in for security and/or confidentiality purposes.” And see Col. 10 lines 16-24 discloses, “If it has been determined that the spread value associated with the adjudicated claim is within the thresholds set by the tolerance parameters, then step 218 is invoked to log the transaction to be made part of a report of the audit results related to that transaction. Such a report may be consolidated with the reports of other logged transactions and/or transmitted (or made accessible) to a third party (e.g., pharmacy, PBM, payer system, etc.).” / examiner notes under BRI the reports of logged transactions audit results is an audit document comprising documents and data associated with the prescription)
As per claim 2, Rowe teaches:
The method of claim 1, further comprising receiving, from a user interface in communication with the processor, user input related to one or more of: the one or more documents or the data associated with the at least one medication prescription being audited. (Col. 5 lines 13-30 discloses, “To enable the provider to input claims for electronic transmission to the claim processing system and payer, the pharmacy POS device 102 may comprise Software that receives claim data entered by a user through a graphical user interface (GUI). In one example embodiment, no claim processing Software resides on the pharmacy POS device 102, other than an Internet browser, because the GUI and one or more interfaces for inputting claim data are stored by the claim processing system and remotely accessible by the pharmacy POS device 102 via an Internet connection, satellite or cellular network, LAN, WAN, or the like. Using the GUI information such as a patient’s name, birth date, address, telephone number and other identifying information is entered with claim-specific information, Such as drug prescription or medical service or procedure. The identity of the pharmacy is also included in the claim data along with additional information known to those of ordinary skill in the art. The claim data fields may be defined by a particular payer such that the pharmacy POS device 102 should provide only the claim data requested by the payer to which the claim is transmitted. The claim data may also be defined by a preestablished standard or transaction format well known to those of skill in the art. Once the claim is entered, it is trans mitted to the host server 104 via any of the methods described above. The claim is then edited by the host server 104 and/or forwarded by the host server 104 to the appropriate pharmacy benefit management service (PBM) 107 and/or payer system 108.”)
As per claim 3, Rowe teaches:
The method of claim 2, wherein the user input comprises an indication of the one or more documents associated with the at least one medication prescription being audited. (Col. 5 lines 13-30 discloses, “To enable the provider to input claims for electronic transmission to the claim processing system and payer, the pharmacy POS device 102 may comprise Software that receives claim data entered by a user through a graphical user interface (GUI). In one example embodiment, no claim processing Software resides on the pharmacy POS device 102, other than an Internet browser, because the GUI and one or more interfaces for inputting claim data are stored by the claim processing system and remotely accessible by the pharmacy POS device 102 via an Internet connection, satellite or cellular network, LAN, WAN, or the like. Using the GUI information such as a patient’s name, birth date, address, telephone number and other identifying information is entered with claim-specific information, Such as drug prescription or medical service or procedure. The identity of the pharmacy is also included in the claim data along with additional information known to those of ordinary skill in the art. The claim data fields may be defined by a particular payer such that the pharmacy POS device 102 should provide only the claim data requested by the payer to which the claim is transmitted. The claim data may also be defined by a preestablished standard or transaction format well known to those of skill in the art. Once the claim is entered, it is trans mitted to the host server 104 via any of the methods described above. The claim is then edited by the host server 104 and/or forwarded by the host server 104 to the appropriate pharmacy benefit management service (PBM) 107 and/or payer system 108.”)
As per claim 4, Rowe teaches:
The method of claim 1, wherein generating the audit document comprises processing, using the processor, the audit request to generate the data associated with the at least one medication prescription being audited. (Col. 6 lines 40-47 discloses, “Further, in an example embodiment of the invention, the audits may be conducted in batch format and a report may be generated with analysis on one or more adjudicated claims. In a batch mode, the auditing process conducted by the spread auditing module 123 may be done retrospectively on previous adjudicated claims that are stored in a database. The auditing process of example embodiments of the invention may be conducted periodically or as requested.” And see Col. 11 lines 65-67 and Col. 12 lines 1- 6 discloses, “FIG. 3, in step 306, the comments/notations are stored with (or otherwise associated with) the transaction data (e.g., adjudicated claim data, spread auditing result data, etc.) for future reference and association. Finally, step 308 is invoked where the comments/notations explaining the nature of the flagged transactions and/or any corrective measures to be taken may be placed in a report to be transmitted to or accessed by the party requesting the audit information (e.g., pharmacy, PBM, payer system, host server provider, etc.)”) / examiner notes the disclosure gives e.g. to generation of an audit which may be based on request into a report with the audit details and inputs)
As per claim 5, Rowe teaches:
The method of claim 1, wherein identifying the one or more documents comprises querying the database, using the processor, with a reference identifier associated with the at least one medication prescription being audited to identify the one or more documents. (Col. 8 lines 17-40 discloses, “FIG. 2 shows a block diagram flowchart showing the process of monitoring and auditing the reimbursed claim in accordance with an example embodiment of the invention. As shown in the example embodiment of FIG. 2, the process starts at step 202 where an adjudicated claim previously received at a host server and stored in a database associated with the host server is retrieved (or imported) to undergo the spread auditing process. In an example embodiment of the invention, a customers (e.g., pharmacy) initial reimbursement claim(s), having been adjudicated by a PBM (e.g., insurance processor or group of insurance processors), and may be stored (or identified) in a spread evaluation table located in one or more databases associated with the spread auditing module. In an alternative embodiment of the invention, rather than being retrieved from a database, an adjudicated claim may undergo the auditing process in real-time or near real time once received at the host server. At the host server, the spread auditing module may parse the relevant data to be utilized in the auditing process. For example, the prescription information (e.g., drug name, quantity, date fulfilled, etc.) may be extracted from the previously adjudicated claim. The specific amount (or cost) reimbursed by the PBM for that particular transaction may also be extracted from the adjudicated claim.” / examiner notes under BRI the process of parsing and extracting information specific to identifier references such as e.g. drug name, quantity, etc. is used to identify the adjudicated claim documentation.)
As per claim 6, Rowe teaches:
The method of claim 5, wherein the audit request further comprises the reference identifier associated with the at least one medication prescription being audited. (Col. 8 lines 17-40 discloses, “FIG. 2 shows a block diagram flowchart showing the process of monitoring and auditing the reimbursed claim in accordance with an example embodiment of the invention. As shown in the example embodiment of FIG. 2, the process starts at step 202 where an adjudicated claim previously received at a host server and stored in a database associated with the host server is retrieved (or imported) to undergo the spread auditing process. In an example embodiment of the invention, a customers (e.g., pharmacy) initial reimbursement claim(s), having been adjudicated by a PBM (e.g., insurance processor or group of insurance processors), and may be stored (or identified) in a spread evaluation table located in one or more databases associated with the spread auditing module. In an alternative embodiment of the invention, rather than being retrieved from a database, an adjudicated claim may undergo the auditing process in real-time or near real time once received at the host server. At the host server, the spread auditing module may parse the relevant data to be utilized in the auditing process. For example, the prescription information (e.g., drug name, quantity, date fulfilled, etc.) may be extracted from the previously adjudicated claim. The specific amount (or cost) reimbursed by the PBM for that particular transaction may also be extracted from the adjudicated claim.”)
As per claim 7, Rowe teaches:
The method of claim 1, further comprising receiving, from a user interface in communication with the processor, an indication from a user verifying an accuracy of the audit document. (Col. 11 lines 11-52 discloses, “FIG.3 shows a block diagram flowchart showing the process of providing comment or explanation of exceptions to the expected audit values in accordance with an example embodiment of the invention. In an example embodiment of the invention, the PBM (or specific payer system) has the ability to provide comments or explanations for the discrepancy Such as an exception(s) to the contracted rates detected by the spread auditing module. In an example embodiment of the invention, the explanations may be entered through a graphical user interface online via a web browser and hosted by the host server or other data center. As shown in FIG.3, the exception reporting process begins at step 302 where an adjudicated claim that had been previously flagged as not being reimbursed according to the contracted obligations is presented, via an online user interface, to a representative of the PBM (or specific payer system) that adjudicated the claim. Next step 304 is invoked, where the representative of the PBM (or specific payer system) has the ability to enter comments on the transaction through the user interface to provide an explanation relating to the adjudicated claim. For example, an explanation may include noting a contractual obligation unaccounted for in the auditing system or some other explanation relating to the detected spread calculation discrepancy. Other comments that may be logged by the representative may include the corrective measures to be taken to fulfill the necessary contractual obligations of the PBM (or payer system) with regard to the flagged claim and/or other relevant information relating to the adjudicated claim or the contractual obligations of the PBM (or payer system). Explanations of flagged transactions may be applied to each individual adjudicated claim or adjudicated claims in bulk. Thus, comments may be global in nature to all flagged adjudicated claims that are related in Subject matter, error detected, or in Some other way that results in the representative providing the same or similar explanation to those adjudicated claims. In alternative embodiments of the invention, the comments/explanations may be automated and provided by an automated response system, which determines the category of the detected discrepancy and determines the appropriate response which may be retrieved from a database or automatically generated, depending on the complexity of the necessary comments/explanation indicated for inclusion.”)
As per claim 8, Rowe teaches:
The method of claim 1, further comprising transmitting the audit document from the processor to a pharmacy benefit manager server. (Col.12 lines 1-6 discloses, “Finally, step 308 is invoked where the comments/notations explaining the nature of the flagged transactions and/or any corrective measures to be taken may be placed in a report to be transmitted to or accessed by the party requesting the audit information (e.g. pharmacy, PBM, payer system, host server provider, etc.)”)
As per claim 10, Rowe teaches:
The method of claim 1, further comprising: receiving, at the processor, an audit response comprising an indication of a subset of the at least one medication prescription being audited that has a discrepancy; and updating the database, using the processor, to denote that the subset of the at least one medication prescription being audited has the discrepancy. (Col. 10 lines 25-34 discloses, “If it has been determined that the spread value associated with the adjudicated claim is not within the thresholds set by the tolerance parameters (i.e., an unacceptable discrepancy or difference), then step 214 is invoked to store or (log) the adjudicated claim and provide the adjudicated claim information to be part of an exceptions report to be provided (or made accessible) to the PBM (or specific payer system) responsible for adjudicating that particular reimbursement claim.” And see Col. 9 lines 38-49 discloses, “In an example embodiment of the invention, the actual spread percentage (or monetary value) and/or the expected spread percentage (or monetary value) may be retrieved from a database, or alternatively, either or both of the actual spread percentage (or monetary value) and the expected spread per centage (or monetary value) may be calculated based on information contained in the adjudicated claim, AWP values associated with the adjudicated claim, policy data associated with the PBM or a specific payer system, etc. Such informa tion used in calculation may be retrieved from one or more data storage locations including the spread evaluation table or other database location”)
As per claim 11, Rowe teaches:
The method of claim 10, wherein the audit response further comprises a clawback value associated with the subset of the at least one medication prescription being audited that has the discrepancy. (Col. 10 lines discloses, “Step 216 may also be invoked to calculate the actual discrepancy between the amount paid and the amount due and Such discrepancy along with the logged transaction may be reported in step 218, which is discussed above. For the purposes of providing example of the detection and auditing of spread discrepancies, the following example is provided which ignores transaction costs and other charges associated with the reimbursement claim adjudication for simplicity. An adjudicated claim for drug A is received and stored at the host server and its reimbursed value is S55. The AWP corresponding to the drug is retrieved and is detected to be $100 and, according to the retrieved policy data, the payer is contractually obligated to reimburse 50% of the drug cost, or S50. Therefore, ignoring other expenses and/or charges for simplicity, the additional S5 is determined to be the PBM's spread charge that was paid by the payer system the PBM represents. At this point the contractual obligation between the payer system and the PBM for the relevant transaction type is access and the contractual spread rate is calculated. If the calculated spread is $4.97 and the tolerance parameter is set to ignore discrepancies of +/-S0.05, the transaction is not flagged. However if the calculated spread is S4, and the tolerance parameter is set to ignore discrepancies of +/-S0.05, the difference between the actual and calculated spread value is too great. In that situation, that transaction is flagged for reporting to the adjudicating PBM (or specific payer system or both) for explanation as to the discrepancy or correction of the discrepancy.”)
As per claims 18-20, they are system claims which repeat the same limitations of claims 1, 2, and 5, the corresponding method claims, as a collection of elements as opposed to a series of process steps. Since the teachings of Rowe disclose the underlying process steps that constitute the methods of claims 1, 2, and 5, it is respectfully submitted that they provide the underlying structural elements that perform the steps as well. As such, the limitations of claims 18-20 are rejected for the same reasons given above for claims 1, 2, and 5.
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.
Claims 9 and 12 are rejected to under 35 U.S.C. 103 as being unpatentable over Rowe III et. al (hereinafter Rowe) (US8489411B1) in view of Patel (US20210050078A1)
As per claim 9, Rowe does not teach:
The method of claim 1, further comprising displaying, on a user interface in communication with the processor, a current status of the audit of the at least one medication prescription being audited.
However, Patel teaches:
The method of claim 1, further comprising displaying, on a user interface in communication with the processor, a current status of the audit of the at least one medication prescription being audited. ([0040] discloses, “Systems and methods for performing an audit are also described . The system uses unique approaches to retrieve claims from the central database . A sample size from the retrieved set of claims is then screened and selected to be audited based on a plurality of factors . A pass / fail result is then produced . The system then produces an audit note and summary of the audit . The system applies deep learning and artificial intelligence concepts to provide suggestions for enhancing audit efficiency and accuracy and minimizing future audit fails . When a party fails an audit , the system is capable of placing them on a corrective action plan . The audit is automated and the steps as well as the results are stored in the central database as well as posted to the blockchain.” And see [0068] discloses, “Further , when a party raises a dispute or a complaint , all the involved parties to that transaction may be informed and be able to review the transaction details such” and see [0060]-[0062] and see [0074] discloses, “Although a Patient 420 , a Primary Physician 430 , and a Specialist 440 are shown , the present invention contemplates the same methodology for transactions between other entities of the present invention as shown in FIGS . 1-3 in this application , e.g. , Healthcare Provider , Payer , Payer System , Health Plan Provider , Pharmacy , Laboratory , Member , Clinics , Hospitals , Auditors , Regula tory Agencies , and any other authorized entities that take part in the overall healthcare process for delivering , man aging , administering , or authorizing healthcare for a patient . However , for exemplary purposes , FIG . 4 focuses on the interactions , transactions , and events between a Patient 420 , a Primary Physician 430 , and a Specialist 440.” )
It would be obvious to one of ordinary skill in the art before the effective filing date of the claimed invention to combine Rowe’s teachings with Patel’s teachings, the motivation being Rowe discloses, adjudication of prescription claims to a decision as previously cited and Patel also teaches the adjudication of claims such as prescription related claims to a decision as previously cited therefore it would be predictable and improve the efficiency of the audits to display a status of the audit.
As per claim 12, Rowe does not teach:
The method of claim 10, wherein the discrepancy comprises an indication of insufficient documentation related to the subset of at least one medication prescription being audited that has the discrepancy.
However, Patel does teach:
The method of claim 10, wherein the discrepancy comprises an indication of insufficient documentation related to the subset of at least one medication prescription being audited that has the discrepancy. ([0148] discloses, “In addition to benefiting the parties in dispute resolution , the present invention also aids the parties in expeditious exchange of information , such as in real - time , that may be needed to process a claim . At times , a claim may be missing details that are required by the payer to process the claim . Certain Payers in the past have taken advantage of the missing information to delay the processing of the claim or simply not respond . The present invention logs all data centrally and alternatively in a blockchain . As such , the status of the claim , the processing timeline , along with all content of the claims are available to all the parties and optionally available in real - time . A party that needs the missing information can flag the claim as such and all the relevant parties would see which piece of information is missing and have the ability to respond or post the missing information . Alternatively , the Control / Verification Manager 809 may send a message or alert to the parties that holds the missing information such that they may expeditious respond or post the missing information thereby expediting the whole process for claim payments.”)
It would be obvious to one of ordinary skill in the art before the effective filing date of the claimed invention to combine Rowe’s teachings with Patel’s teachings for the same reasons given for claim 9.
Claim 13 is rejected to under 35 U.S.C. 103 as being unpatentable over Rowe III et. al (hereinafter Rowe) (US8489411B1) in view of Mensh (US20250095815A1)
As per claim 13, Rowe does not teach:
The method of claim 10, further comprising: identifying, using the processor, one or more prescription appeal documents in the database, wherein the one or more prescription appeal documents are associated with the subset of the at least one medication prescription being audited that has the discrepancy; retrieving, from the database to the processor, the one or more prescription appeal documents; and generating, using the processor, an appeal document related to the subset of the at least one medication prescription being audited that has the discrepancy, wherein the appeal document comprises the one or more prescription appeal documents and appeal data associated with the subset of the at least one medication prescription being audited that has the discrepancy.
However, Mensh does teach:
The method of claim 10, further comprising: identifying, using the processor, one or more prescription appeal documents in the database, wherein the one or more prescription appeal documents are associated with the subset of the at least one medication prescription being audited that has the discrepancy; retrieving, from the database to the processor, the one or more prescription appeal documents; ([0021] discloses, “The present invention provides a method of creating a request pertaining to a prescription drug. The method includes drafting an appeal, after a claim requesting at least partial insurance coverage of a cost associated with the prescription drug has been submitted to an insurance benefits manager, a notification that prior authorization has been denied. A secured computer system is provided for enabling the method.”) and generating, using the processor, an appeal document related to the subset of the at least one medication prescription being audited that has the discrepancy, wherein the appeal document comprises the one or more prescription appeal documents and appeal data associated with the subset of the at least one medication prescription being audited that has the discrepancy. ([01385] discloses, “The present inventive method facilitates creation of a letter of medical necessity, an appeal, or request for formulary exception for prescriptions for a patient based upon a unique combination of factors from potentially each of these sources.” And see [0218] discloses, “In this hypothetical case, the physician is filing an appeal so that the patient may have access to the representative pharmaceutical, windogo, which is in this case, being prescribed for rheumatoid arthritis.” And see [0380] discloses, “As before, the user can review the compiled information included in the final letter 200 including the business letterhead 28, suggested greeting 201, patient information 110 (specifically bibliographic information 111, 112, insurance information 115, 116), statement of purpose 202, summary of diagnosis 203, further details 204, summary of request for treatment 205, and conclusion 206.”)
It would be obvious to one of ordinary skill in the art before the effective filing date of the claimed invention to combine Rowe’s teachings with Mensh’s teachings, the motivation being Rowe teaches claim adjudication as previously cited for prescriptions and Mensh teaches claim adjudication for prescriptions inclusive of appeals therefore it would be predictable to use the computer elements in Rowe to follow the same process whether its an appeal document or audit document with improved transparency to final determination.
Claim 14 is rejected to under 35 U.S.C. 103 as being unpatentable over Rowe III et. al (hereinafter Rowe) (US8489411B1) in view of Sutters et. al (hereinafter Sutters) (US20230197210A1)
As per claim 14, Rowe does not teach:
The method of claim 13, further comprising transmitting the appeal document from the processor to a pharmacy benefit manager server.
However, Sutters does teach:
The method of claim 13, further comprising transmitting the appeal document from the processor to a pharmacy benefit manager server. ([0042] discloses, “Healthcare requests may include, for example, a prescription benefit check request and/or an electronic prior authorization request (e.g., an electronic prior authorization initiation request, an electronic prior authorization request, an electronic prior authorization appeal request, and/or an electronic prior authorization cancel request formatted under the NCPDP Script Standard for example).” And see [0051] discloses, “The healthcare request processing module 156 may be a software application, including, but not limited to, a dedicated program configured for receiving electronic healthcare requests (including electronic prior authorization requests and/or prescription benefit check requests) from prescriber/healthcare provider computers 102 associated with (e.g., located within or otherwise under the control and administration of) prescribers of medication (e.g., physicians, dentists, nurse practitioners, hospitals, physicians offices, clinics, or any other person or entity legally authorized to prescribe medications, products, or services to patients) either directly or via an EMR vendor/aggregator system 115, and pharmacy computers 108 associated with (e.g., located within or otherwise under the control and administration of) pharmacies, conducting edit or analysis actions on the electronic healthcare requests, and, in some situations, forwarding the electronic healthcare requests to a pharmacy claims processor computer 106 associated with (e.g., located within or otherwise under the control and administration of) a pharmacy claims processor or benefits provider (e.g., pharmacy benefits manager (PBM), insurance provider, government insurance provider (e.g., Medicare, Medicaid)) or a prior authorization clearinghouse.”)
It would be obvious to one of ordinary skill in the art before the effective filing date of the claimed invention to combine Rowe’s teachings with Sutter’s teachings, the motivation being Rowe already communicates with a PBM as previously cited therefore it would be predictable to communicate any audit document including appeal’s in Sutter as needed.
Claim 15 is rejected to under 35 U.S.C. 103 as being unpatentable over Rowe III et. al (hereinafter Rowe) (US8489411B1) in view of Pinsonneault et. al (hereinafter Pinsonneault) (US10742654B1)
As per claim 15, Rowe does not teach:
The method of claim 13, further comprising: receiving, at the processor, an appeal response comprising an indication of a final determination related to the subset of the at least one medication prescription being audited that has the discrepancy; and updating the database, using the processor, to denote that the subset of the at least one medication prescription being audited that has the discrepancy has had a final determination.
However, Pinsonneault does teach:
The method of claim 13, further comprising: receiving, at the processor, an appeal response comprising an indication of a final determination related to the subset of the at least one medication prescription being audited that has the discrepancy; and updating the database, using the processor, to denote that the subset of the at least one medication prescription being audited that has the discrepancy has had a final determination. (Col. 26 lines 10-61 discloses, an example of a type of request such as an appeal request with corresponding information that is then given denial or approval and reasoning why )
It would be obvious to one of ordinary skill in the art before the effective filing date of the claimed invention to combine Rowe’s teachings with Pinsonneault’s teachings, the motivation being Rowe already teaches updating and storing the audit information in databases as previously cited, therefore it would be predictable to combine with Pinsonneault as any document of choice can be saved which may relate to an audit such as appeal documents with discrepancies and final determination.
Claims 16 and 17 are rejected to under 35 U.S.C. 103 as being unpatentable over Rowe III et. al (hereinafter Rowe) (US8489411B1) in view of Samarin et. al (hereinafter Samarin) (US10776890B1)
As per claim 16, Rowe does not teach:
The method of claim 1, further comprising processing, using an artificial intelligence algorithm executing on the processor, data associated with the at least one medication prescription to determine one or more characteristics of the at least one medication prescription that is likely to be audited.
However, Samarin does teach:
The method of claim 1, further comprising processing, using an artificial intelligence algorithm executing on the processor, data associated with the at least one medication prescription to determine one or more characteristics of the at least one medication prescription that is likely to be audited. (figs. 10A-10E and Col. 2 lines 35-38 and Col. 23 lines 53-67 and Col. 24 lines 1-24 discloses, using machine learning models to determine likelihood of fraud waste abuse auditing based on things like pharmacy, drug data etc.)
It would be obvious to one of ordinary skill in the art before the effective filing date of the claimed invention to combine Rowe’s teachings with Samarin’s teachings, the motivation being the artificial intelligence algorithms in Samarin would improve the efficiency and accuracy of audits and improve transparency which Rowe teaches is a concern (see Col. 1 lines 25-45)
As per claim 17, Rowe does not teach:
The method of claim 16, further comprising generating, using the artificial intelligence algorithm executing on the processor, a risk score associated with the at least one medication prescription, wherein the risk score relates to a likelihood of the at least one medication prescription being audited.
However, Samarin does teach:
The method of claim 16, further comprising generating, using the artificial intelligence algorithm executing on the processor, a risk score associated with the at least one medication prescription, wherein the risk score relates to a likelihood of the at least one medication prescription being audited. (Figs. 10A-10E and see Col. 2 lines 35-38 and Col. 23 lines 53-67 and Col. 24 lines 1-24 and see Col. discloses, using machine learning models to determine likelihood through risk scoring of fraud waste abuse auditing based on things like pharmacy, drug data etc.)
It would be obvious to one of ordinary skill in the art before the effective filing date of the claimed invention to combine Rowe’s teachings with Samarin’s teachings, for the same reasons given above for claim 16.
Prior Art not cited but made of record
US10497077B1 - LaVahn
The present invention is a computer implemented method and system for gathering information from a user related to , filing for , and obtaining government benefits , such as Social Security benefits . The present invention also enables the user to track the benefit application approval process and reminders when certain data or responses are due . There is a feature which enables the user to modify the data submitted for the benefits when circumstances warrant . There is also a decision appeal process feature .
Conclusion
Any inquiry concerning this communication or earlier communications from the examiner should be directed to Ashley Elizabeth Evans whose telephone number is (571) 270-0110. The examiner can normally be reached Monday – Friday 8:00 AM – 5:00 PM.
If attempts to reach the examiner by telephone are unsuccessful, the examiner’s supervisor, Mamon Obeid can be reached on (571) 270-1813. The fax phone number for the organization where this application or proceeding is assigned 571-273-8300.
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/ASHLEY ELIZABETH EVANS/Examiner, Art Unit 3687
/MAMON OBEID/Supervisory Patent Examiner, Art Unit 3687