DETAILED ACTION
Notice of Pre-AIA or AIA Status
The present application, 19/098,347, was filed on 04/02/2025, and claims priority from U.S. Provisional Application 63/573,855 and 63/573,753, filed 04/03/2024.
The effective filing date is after the AIA date of March 16, 2013, and so the application is being examined under the “first inventor to file” provisions of the AIA .
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 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.
Status of the Application
This Final Office Action is in response to Applicant’s communication of 07/01/2026.
Claims 1-20 are pending, of which claims 1 and 12 are independent.
All pending claims have been examined on the merits.
Claim Objections
Claim 12 is objected to because of the following informalities: “validating the claim requests in real time and based on the retrieved eligibility information, the claim requests” should be amended to recite “validating the claim requests in real time and based on the retrieved eligibility information”. Appropriate correction is required.
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 under 35 U.S.C. §101 because the claimed invention is directed to non-statutory subject matter. The claimed invention is directed to an abstract idea, without “significantly more”.
Based on the flowchart in MPEP § 2106, Step 1 of the Alice/Mayo analysis is: “Is the claim to a process, machine, manufacture or composition of matter?”
In regards to Step 1 of the Alice/Mayo analysis, independent claim 1 is a method claim, and claim 12 is an apparatus claim.
For the sake of compact prosecution, we continue with the Alice/Mayo “abstract idea” analysis.
Step 2A, prong 1 of the Alice/Mayo analysis is: “Does the claim recite a law of nature, a natural phenomenon (product of nature), or an abstract idea?”
In regards to Step 2A, prongs 1 and 2 of the Alice/Mayo analysis, the abstract idea elements recited in independent claim 12 are shown in italic font. (The “additional elements” and “extra solution steps” are shown in italic and underlined font):
12. (Currently Amended) A claims processing hub configured to integrate a
plurality of providers and a plurality of payors to process claims made by a plurality of service providers to the plurality of payors, the claims processing hub comprising:
a processor; and
a computer readable medium coupled to the processor, the computer readable medium comprising instructions for causing the processor to perform a method comprising:
receiving claim requests from a plurality of service provider computers associated with the plurality of service providers for fulfillment by the plurality of payors, each claim request including service provider information, payor information, and beneficiary information, wherein the plurality of service providers include healthcare service providers;
retrieving, by the processing hub from a database associated with the processing hub, eligibility information received during enrollment of the plurality of service providers and the plurality of payors, the eligibility information including healthcare beneficiary plan information and information relating the plurality of service providers to the plurality of payors;
validating the claim requests in real time and based on the retrieved eligibility information, the claim requests;
generating, by the processing hub for each validated claim request, a record comprising an amount to be transferred to a respective service provider based on respective validated claim request;
determining, during a settlement window, for each service provider of the plurality of service providers, a net amount to be transferred to the service provider, the net amount associated with a plurality of claim requests made by the service provider for different beneficiaries serviced by the service provider, the different beneficiaries associated with different payors; and
facilitating for each of the service providers, a single funds transfer in the net amount to be transferred to the service provider, wherein the single funds transfer is initiated on a same day that the processing hub receives corresponding claim requests for the records aggregated to determine the net amount.
More specifically, claims 1-20 recite an abstract idea: “Commercial or Legal Interactions (Including Agreements in the form of Contracts; Legal Obligations; Advertising, Marketing, or Sales Activities or Behaviors; Business Relations)”, as discussed in MPEP §2106(a)(2) Parts (I) and (II), and in the 2019 Revised Patent Subject Matter Eligibility Guidance.
The “Commercial or Legal Interactions” elements include:
“each claim request including service provider information, payor information, and beneficiary information, wherein the plurality of service providers include healthcare service providers”.
“the eligibility information including healthcare beneficiary plan information and information relating the plurality of service providers to the plurality of payors”.
“validating the claim requests … and based on the retrieved eligibility information, the claim requests”.
“determining … for each service provider of the plurality of service providers, a net amount to be transferred to the service provider, the net amount associated with a plurality of claim requests made by the service provider for different beneficiaries serviced by the service provider, the different beneficiaries associated with different payors”.
“facilitating for each of the service providers, a single funds transfer in the net amount to be transferred to the service provider”.
Moreover, claims 1-20 recite “Mathematical Concepts", specifically “Mathematical Relationships”, “Mathematical Formulas or Equations”, and “Mathematical Calculations”, as discussed in MPEP §2106.04(a)(2) Part (IV), and in the 2019 Revised Patent Subject Matter Eligibility Guidance.
The mathematical elements include:
“determining … for each service provider of the plurality of service providers, a net amount to be transferred to the service provider, the net amount associated with a plurality of claim requests made by the service provider for different beneficiaries serviced by the service provider, the different beneficiaries associated with different payors”.
The “additional elements” include: “a processor”, “a computer readable medium”, and “a plurality of service provider computers”.
Moreover, “additional extra-solution elements” include: “the computer readable medium comprising instructions for causing the processor to perform a method”, “receiving claim requests from a plurality of service provider computers associated with the plurality of service providers for fulfillment by the plurality of payors”, “retrieving, by the processing hub from a database associated with the processing hub, eligibility information received during enrollment of the plurality of service providers and the plurality of payors”, “generating, by the processing hub for each validated claim request, a record comprising an amount to be transferred to a respective service provider based on respective validated claim request”, and “facilitating for each of the service providers, a single funds transfer in the net amount to be transferred to the service provider”.
Step 2A, prong 2 of the Alice/Mayo analysis is “Does the claim recite additional elements that integrate elements that integrate the judicial exception into a practical application?”
In regards to Step 2A, prong 2 of the Alice/Mayo analysis, this abstract idea is not integrated into a practical application, because:
The claim is directed to an abstract idea with additional generic computer elements. The generically recited computer elements (“a processor”, “a computer readable medium”, and “a plurality of service provider computers”) do not add a meaningful limitation to the abstract idea, because they amount to simply implementing the abstract idea on a computer. The claim amounts to adding the words "apply it" (or an equivalent) with the abstract idea, or mere instructions to implement an abstract idea on a computer, or merely uses a computer as a tool to perform an abstract idea.
The extra-solution activities (“the computer readable medium comprising instructions for causing the processor to perform a method”, “receiving claim requests from a plurality of service provider computers associated with the plurality of service providers for fulfillment by the plurality of payors”, “retrieving, by the processing hub from a database associated with the processing hub, eligibility information received during enrollment of the plurality of service providers and the plurality of payors”, “generating, by the processing hub for each validated claim request, a record comprising an amount to be transferred to a respective service provider based on respective validated claim request”, and “facilitating for each of the service providers, a single funds transfer in the net amount to be transferred to the service provider”) do not add a meaningful limitation to the method, as they are insignificant extra-solution activity;
The combination of the abstract idea with the additional elements (generically recited computer elements), and/or with the extra-solution activities, does not integrate the abstract idea into a practical application.
Step 2B of the Alice/Mayo analysis is: “Does the claim recite additional elements that amount to significantly more than the judicial exception?”
In regards to Step 2B of the Alice/Mayo analysis, the claims do not include additional elements that are sufficient to amount to significantly more than the abstract idea, because:
When considering the elements "alone and in combination" (“a processor”, “a computer readable medium”, and “a plurality of service provider computers”), they do not add significantly more (also known as an "inventive concept") to the exception, because they amount to simply implementing the abstract idea on a computer. Instead, they merely add the words "apply it" (or an equivalent) with the abstract idea, or mere instructions to implement an abstract idea on a computer, or merely use a computer as a tool to perform an abstract idea.
In regards to the extra solution activities (“the computer readable medium comprising instructions for causing the processor to perform a method”, “receiving claim requests from a plurality of service provider computers associated with the plurality of service providers for fulfillment by the plurality of payors”, “retrieving, by the processing hub from a database associated with the processing hub, eligibility information received during enrollment of the plurality of service providers and the plurality of payors”, “generating, by the processing hub for each validated claim request, a record comprising an amount to be transferred to a respective service provider based on respective validated claim request”, and “facilitating for each of the service providers, a single funds transfer in the net amount to be transferred to the service provider”), these are recognized as such by the court decisions listed in MPEP § 2106.05(d).
More specifically, in regards to the “storing” step (“the computer readable medium comprising instructions”), see the court cases Versata Dev. Group, Inc. v. SAP Am., Inc., 793 F.3d 1306, 1334, 115 USPQ2d 1681, 1701 (Fed. Cir. 2015) (storing and retrieving information in memory); and OIP Techs., Inc., v. Amazon.com, Inc., 788 F.3d 1359, 1363, 115 USPQ2d 1090, 1092-93 (Fed. Cir. 2015) (storing and retrieving information in memory).
More specifically, in regards to the “receiving”, “retrieving”, and “transferring” steps (“receiving claim requests from a plurality of service provider computers associated with the plurality of service providers for fulfillment by the plurality of payors”, “retrieving, by the processing hub from a database associated with the processing hub, eligibility information received during enrollment of the plurality of service providers and the plurality of payors”, and “facilitating for each of the service providers, a single funds transfer in the net amount to be transferred to the service provider”), see the court cases OIP Techs., Inc., v. Amazon.com, Inc., 788 F.3d 1359, 1363, 115 USPQ2d 1090, 1093 (Fed. Cir. 2015) (sending messages over a network) and (presenting offers and gathering statistics), OIP Techs., 788 F.3d at 1362-63, 115 USPQ2d at 1092-93; buySAFE, Inc. v. Google, Inc., 765 F.3d 1350, 1355, 112 USPQ2d 1093, 1096 (Fed. Cir. 2014) (computer receives and sends information over a network).
Moreover, in regards to the “displaying” or “generating, by the processing hub for each validated claim request, a record” steps, see Apple, Inc. v. Ameranth, Inc., 842 F.3d 1229, 120 U.S.P.Q.2d 1844 (Fed. Cir. 2016) (Holding that the claimed menu graphic user interface is an abstract idea under 35 USC §101, because claimant "[did] not claim a particular way of programming or designing the software to create menus that have these features, but instead merely claims the resulting systems").
Moreover, in regards to “apply it”, according to MPEP § 2106.05(f)(2):
Use of a computer or other machinery in its ordinary capacity for economic or other tasks (e.g., to receive, store, or transmit data) or simply adding a general purpose computer or computer components after the fact to an abstract idea (e.g., a fundamental economic practice or mathematical equation) does not integrate a judicial exception into a practical application or provide significantly more. See Affinity Labs v. DirecTV, 838 F.3d 1253, 1262, 120 USPQ2d 1201, 1207 (Fed. Cir. 2016) (cellular telephone); TLI Communications LLC v. AV Auto, LLC, 823 F.3d 607, 613, 118 USPQ2d 1744, 1748 (Fed. Cir. 2016) (computer server and telephone unit). Similarly, "claiming the improved speed or efficiency inherent with applying the abstract idea on a computer" does not integrate a judicial exception into a practical application or provide an inventive concept. Intellectual Ventures I LLC v. Capital One Bank (USA), 792 F.3d 1363, 1367, 115 USPQ2d 1636, 1639 (Fed. Cir. 2015).
In contrast, a claim that purports to improve computer capabilities or to improve an existing technology may integrate a judicial exception into a practical application or provide significantly more. McRO, Inc. v. Bandai Namco Games Am. Inc., 837 F.3d 1299, 1314-15, 120 USPQ2d 1091, 1101-02 (Fed. Cir. 2016); Enfish, LLC v. Microsoft Corp., 822 F.3d 1327, 1335-36, 118 USPQ2d 1684, 1688-89 (Fed. Cir. 2016). See MPEP §§ 2106.04(d)(1) and 2106.05(a) for a discussion of improvements to the functioning of a computer or to another technology or technical field.
The Examiner holds that performing the “validating” task “in real time”, and the “determining … a net amount” task “during a settlement window” as recited in the independent claims 1 and 12, is equivalent to reciting that the “validating … in real time” and “determining, during a settlement window … a net amount” tasks are “apply it” performed on a generic general purpose computer.
The Examiner holds that the independent claims “use a computer or other machinery in its ordinary capacity for economic or other tasks (e.g., to receive, store, or transmit data)” or “simply add a general purpose computer or computer components after the fact to an abstract idea”.
Independent claim 1 is rejected on the same grounds as independent claim 12.
All dependent claims are also rejected, because they merely further define the abstract idea.
Claim Rejections - 35 USC § 103
This application currently names joint inventors. In considering patentability of the claims the examiner presumes that the subject matter of the various claims was commonly owned as of the effective filing date of the claimed invention(s) absent any evidence to the contrary. Applicant is advised of the obligation under 37 CFR 1.56 to point out the inventor and effective filing dates of each claim that was not commonly owned as of the effective filing date of the later invention in order for the examiner to consider the applicability of 35 U.S.C. 102(b)(2)(C) for any potential 35 U.S.C. 102(a)(2) prior art against the later invention.
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 set forth in Graham v. John Deere Co., 383 U.S. 1, 148 USPQ 459 (1966), that are applied 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 1-20 are rejected under 35 U.S.C. 103 as being unpatentable over US-2003/0135397-A1 to Harlow et al. (“Harlow”. Eff. Filed on Jan. 11, 2002. Published on Jul. 17, 2003) in view of US-2019/0318431-A1 to Niemeyer (“Niemeyer”. Eff. Filed on Apr. 14, 2018. Published on Oct. 17, 2019).
In regards to claim 1,
1. A method comprising:
receiving, by a processing hub, claim requests from a plurality of service provider computers associated with a plurality of service providers for fulfillment by a plurality of payors,
(See Harlow, para. [0025]: “The system of the present invention 10 is illustrated in FIG. 1. A clearing house 12 is established to process bills generated by a number of medical practitioners directed to a number of private and public insurance entities. This system would verify and pay the plurality of practitioners or providers for the performance of various medical or dental procedures. One such provider is shown at 14. The purpose of the system is to prevent fraud from being perpetuated on the number of insurance entities shown at 16. These insurance entities could include a number of private insurance companies 18, as well as federal insurers, such as one overseeing the workman's compensation system as shown at 20. These public insurers could include medicare, medicaid, as well as other federally-sponsored or state-sponsored programs.”)
each claim request including service provider information, payor information, and beneficiary information,
(See Harlow, para. [0035]: “Instead of entering the information at the time the treatment was administered, the provider may choose to enter all the information for a particular for a particular day, including the provider's identification number, the identification number of each of the patients, as well as the diagnostic and treatment codes associated with each of the treatments at the end of the day. This information could be keyed into the system utilizing either of the two entry systems described hereinabove.”)
wherein the plurality of service providers include healthcare service providers;
(See Harlow, Abstract: “A system and method of determining and preventing fraud in the posting of medical insurance claims in which a clearing house is established for receiving information transmitted from a plurality of providers administering treatment covered by various insurance plans. For example, the clearing house would monitor the information provided by each of the providers to determine whether the providers submitted multiple claims for a particular period of time. The clearing house would also determine whether other inappropriate claims were made by the providers. If the clearing house determines that the treatments were proper, the providers would be paid by the clearing house in a timely manner.”)
(See Harlow, para. [0013]: “The deficiencies of the prior art are addressed by the present invention which is directed to a system and method of endeavoring to eliminate, or at least limit, fraud due to improper or deceptive medical claims procedures being submitted to various private or public insurers for collection by various medical providers.”
validating, by the processing hub in real time and based on the retrieved eligibility information, the claim requests;
(See Harlow, para. [0036]: “The clearing house 12 will then analyze the data to determine whether any fraudulent or inappropriate billing information was submitted. For example, software provided in the clearing house 12 could be used to calculate the amount of treatment time submitted by each particular provider/technician. If a particular provider/technician billed out more treatment hours than was possible, the appropriate insurance entities would be notified. Additionally, this software would have the ability to determine whether a particular treatment code corresponds with the associated diagnosis or treatment request. If this occurs, the appropriate insurance entity would be notified and payment would be denied to the provider. Furthermore, the software according to the present invention would be able to determine whether mutually exclusive treatment codes were submitted for the same patient. If this was the case, payment would also be denied to the provider.”)
(See Harlow, para. [0037]: “Additionally, since the clearing house would monitor claims made by a single provider to a number of different insurance entities, the present invention would be able to determine whether a single provider claimed treatment for more than one patient during a single time period. If this situation occurred, particularly if this information was transmitted from the provider to the clearing house during the same day, payment would be denied to the provider for all claims made during a specific period of time and the appropriate insurance entities would be notified. Finally, if the provider made a claim for a particular period of time and received payment for a treatment during that time, any subsequent claim for that particular period of time would then be denied by the clearing house 12 and the appropriate insurance entity would then be notified.”)
However, under a conservative interpretation of Harlow, it could be argued that Harlow does not explicitly teach the italicized portions below, which are taught by Niemeyer:
retrieving, by the processing hub from a database associated with the processing hub, eligibility information received during enrollment of the plurality of service providers and the plurality of payors, the eligibility information including healthcare beneficiary plan information and information relating the plurality of service providers to the plurality of payors;
(See Niemeyer, para. [0032]: “The episode management platform comprises an episode eligibility system and a claim adjudication system. The episode eligibility system determines eligibility of the patient for bundled payment and the claim adjudication system resolves the claims raised by healthcare service providers. The healthcare professional (e.g., a physician) creates a clinical episode corresponding to the health condition of the patient and checks eligibility of the patient for the bundled payment via the episode eligibility system. The episode eligibility system stores the bundled payment eligibility of members (via eligibility data file feeds from payors) and also retrieves insurance details of the patient from an insurance service provider based on a primary health insurance information. The eligibility files are used by the episode eligibility system to determine the patient's eligibility for bundled payment relating to a particular clinical episode.”)
generating, by the processing hub for each validated claim request, a record comprising an amount to be transferred to a respective service provider based on respective validated claim request;
(See Niemeyer, para. [0061]: “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.”)
determining, by the processing hub during a settlement window, for each service provider of the plurality of service providers, a net amount to be transferred to the service provider, the net amount associated with a plurality of claim requests made by the service provider for different beneficiaries serviced by the service provider, the different beneficiaries associated with different payors; and
(See Niemeyer, para. [0069]: “In an embodiment, upon determining at least one valid claim, the claim settlement unit 312 b is configured to facilitate payment of a payment amount (based on a contracted payment rate) for the health care service associated with the at least one valid claim to the healthcare service provider (e.g., the healthcare service provider 114 a).”)
(See Niemeyer, para. [0126]: “At operation 810, the method 800 includes upon processing the one or more claims, facilitating, by the processor, a payment amount for the one or more claims of the at least one health care service provider based on the validity.”)
facilitating, by the processing hub, for each of the service providers, a single funds transfer in the net amount to be transferred to the service provider, wherein the single funds transfer is initiated on a same day that the processing hub receives corresponding claim requests for the records aggregated to determine the net amount.
(See Niemeyer, para. [0119]: “At operation 704, the employer group is invoiced for the bundled payment claim by an episode underwriter (e.g., the episode underwriter 124). A claim payment request including payment information associated with the bundled payment claim is sent to the employer. The payment information includes a payment amount for the health care service, a payment mode, and an account information of the episode underwriter. At operation 706, the employer makes payment for payment amount associated with the bundled payment to the episode underwriter.”)
(See Niemeyer, para. [0120]: “At operation 708, the bundled payment claim is submitted using the episode underwriter NPI directly to the insurance service provider. At operation 710, the health plan provider (e.g., the insurance service provider 116) pays the requested amount to the episode underwriter.”)
It would have been obvious to a person having ordinary skill in the art (PHOSITA), before the effective filing date of the claimed invention, to combine features in the “Medical billing system to prevent fraud”, as taught by Harlow, with features in “Computer implemented methods and systems for bundled payment adjudication”, as taught by Niemeyer (such as “the net amount associated with a plurality of claim requests made by the service provider for different beneficiaries serviced by the service provider” and “a single funds transfer in the net amount to be transferred to the service provider”, as claimed), because Niemeyer expressly teaches:
(See Niemeyer, para. [0032]: “When a patient visits a healthcare professional with an illness or complications, his health condition is generally diagnosed to carry out the treatment procedures, and accordingly payment plan, schedule, and mode of payment are decided. For instance, if the health condition of the patient requires surgery, extended hospitalization, and post-operative care, the physician may recommend the patient to opt for bundled payment. The bundled payment adjudication of healthcare claims is managed by an episode management platform.”)
In regards to claim 2,
2. The method of claim 1, wherein the payors are insurance companies.
(See Niemeyer, para. [0120]: “At operation 708, the bundled payment claim is submitted using the episode underwriter NPI directly to the insurance service provider. At operation 710, the health plan provider (e.g., the insurance service provider 116) pays the requested amount to the episode underwriter.”)
In regards to claim 3,
3. The method of claim 1, wherein the method occurs at least once per day.
(See Harlow, para. [0035]: “Instead of entering the information at the time the treatment was administered, the provider may choose to enter all the information for a particular for a particular day, including the provider's identification number, the identification number of each of the patients, as well as the diagnostic and treatment codes associated with each of the treatments at the end of the day. This information could be keyed into the system utilizing either of the two entry systems described hereinabove.”)
In regards to claim 4,
4. The method of claim 1, wherein facilitating the single funds transfer for each of the service providers comprises providing an instruction to a payment hub to transfer funds in net amounts to the service provider computers.
The Examiner interprets that the claimed “payment hub” is a bank, and notes that Harlow para. [0030] teaches that “the provider would be timely paid within perhaps one, two or three days, as shown at 28”. Official Notice is given that it would be obvious to use a bank to make such payments.
(See also Harlow, para. [0030]: “Obviously, if fraudulent billing procedures were discovered, the provider would not be paid for these services. However, if the software at the clearing house indicates that the provider has passed the verification process, this data would also be sent to the particular insurance entity for payment. The clearing house would notify the provider that it passed the verification process and the provider would be timely paid within perhaps one, two or three days, as shown at 28. The clearing house 12 would then be compensated by the appropriate insurance entity.”)
In regards to claim 5,
5. The method of claim 1, further comprising:
determining, by the processing hub, for each payor of the plurality of payors, a payor net amount to be transferred by the payor, the payor net amount associated with a plurality of claim requests made by different service providers for different beneficiaries serviced by the different service providers, the different beneficiaries associated with the payor; and
facilitating, by the processing hub, for each of the payors, a single funds transfer in the payor net amount to be transferred by the payor.
(See Niemeyer, [0119]: “At operation 704, the employer group is invoiced for the bundled payment claim by an episode underwriter (e.g., the episode underwriter 124). A claim payment request including payment information associated with the bundled payment claim is sent to the employer. The payment information includes a payment amount for the health care service, a payment mode, and an account information of the episode underwriter. At operation 706, the employer makes payment for payment amount associated with the bundled payment to the episode underwriter.”)
In regards to claim 6,
6. The method of claim 1,
wherein each claim request comprises a claim amount, and wherein the method further comprises generating, for each claim request, a service provider record
(See Harlow, para. [0035]: “Instead of entering the information at the time the treatment was administered, the provider may choose to enter all the information for a particular for a particular day, including the provider's identification number, the identification number of each of the patients, as well as the diagnostic and treatment codes associated with each of the treatments at the end of the day. This information could be keyed into the system utilizing either of the two entry systems described hereinabove.”)
and a payor record based on the claim amount,
(See Harlow, para. [0030]: “Obviously, if fraudulent billing procedures were discovered, the provider would not be paid for these services. However, if the software at the clearing house indicates that the provider has passed the verification process, this data would also be sent to the particular insurance entity for payment. The clearing house would notify the provider that it passed the verification process and the provider would be timely paid within perhaps one, two or three days, as shown at 28. The clearing house 12 would then be compensated by the appropriate insurance entity.”)
wherein the service provider record comprises a first amount to be transferred to a service provider and the payor record comprises a second amount to be transferred from a payor.
The Examiner interprets that the claimed “first amount” is an obvious feature to include in the provider’s “all the information for a particular for a particular day” (see Harlow, para. [0035]), and the “second amount” is an obvious feature to include in the “data would also be sent to the particular insurance entity for payment” (see Harlow, para. [0030]).
In regards to claim 7,
7. The method of claim 6, wherein the net amount to be transferred to the service provider is based on a sum of first amounts determined for the plurality of claim requests made by the service provider.
(See Niemeyer, para. [0069]: “In an embodiment, upon determining at least one valid claim, the claim settlement unit 312 b is configured to facilitate payment of a payment amount (based on a contracted payment rate) for the health care service associated with the at least one valid claim to the healthcare service provider (e.g., the healthcare service provider 114 a).”)
In regards to claim 8,
8. The method of claim 1, wherein validating the claim requests comprises using artificial intelligence to check each claim request for fraud.
(See Harlow, para. [0013]: “The deficiencies of the prior art are addressed by the present invention which is directed to a system and method of endeavoring to eliminate, or at least limit, fraud due to improper or deceptive medical claims procedures being submitted to various private or public insurers for collection by various medical providers.”)
Moreover, the Examiner interprets that the generic recitation of “using artificial intelligence to check each claim request for fraud”is equivalent to broadly claiming “mere automation”. See MPEP § 2144.04(III):
MPEP § 2144.04(III): AUTOMATING A MANUAL ACTIVITY
In re Venner, 262 F.2d 91, 95, 120 USPQ 193, 194 (CCPA 1958) (Appellant argued that claims to a permanent mold casting apparatus for molding trunk pistons were allowable over the prior art because the claimed invention combined "old permanent-mold structures together with a timer and solenoid which automatically actuates the known pressure valve system to release the inner core after a predetermined time has elapsed." The court held that broadly providing an automatic or mechanical means to replace a manual activity which accomplished the same result is not sufficient to distinguish over the prior art.).
In regards to claim 9,
9. (Currently Amended) The method of claim 1, wherein the claim requests are Fast Healthcare Interoperability Resources (FHIR) Application Programming Interface (API) messages.
(See Harlow, para. [0031]: “The software utilized by the present invention could be a self-contained software program in which all billing information is keyed and transmitted. This approach would require all the interfaces for patient and billing information. The system could be used in an office in which no existing software product is included and would therefore require no coordination with existing software providers.”)
The Examiner interprets that the “FHIR API” is one of the “interfaces for patient and billing information”.
(See also Niemeyer, para. [0039]: “The episode eligibility system 120 determines the patient eligibility for the clinical episode based on stored eligibility of members that uses eligibility file provided by payors (e.g., the insurance service provider 116). The eligibility file includes health insurance details of the patient 102. The eligibility files may take the form of EDI 834 files, CSV files or some other type of automated feed or API. The server 112 may contact the insurance service provider 116 through the communication network 110 for acquiring eligibility file associated with the patient 102.”)
In regards to claim 10,
10. The method of claim 1, wherein the beneficiary information comprises a payment credential.
(See Harlow, para. [0035]: “Instead of entering the information at the time the treatment was administered, the provider may choose to enter all the information for a particular for a particular day, including the provider's identification number, the identification number of each of the patients, as well as the diagnostic and treatment codes associated with each of the treatments at the end of the day. This information could be keyed into the system utilizing either of the two entry systems described hereinabove.”)
The Examiner interprets that also including a payment credential information with the information reported by the provider to the clearing house, for each of the beneficiaries, is an obvious variation of Harlow’s para. [0035] disclosure of reporting “the provider's identification number, the identification number of each of the patients, as well as the diagnostic and treatment codes associated with each of the treatments”.
In regards to claim 11,
11. The method of claim 1,
wherein the eligibility information relating the plurality of service providers to the plurality of payors, and
wherein the validating the claim requests comprises determining, for each claim request, service provider information, payor information, and beneficiary information are related based on the eligibility information.
(See Harlow, para. [0014]: “The software would insure that a single medical practitioner has appropriately billed an insurance company, including, but not limited to, insuring that the practitioner has not billed for multiple procedures at the same time. This software would also monitor the billing information to insure that a certain procedure was consistent with a diagnosis or treatment plan based upon entered procedure codes and diagnosis codes.”)
(See Niemeyer, para. [0059]: “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.”
In regards to claim 12, it is rejected on the same grounds as claim 1.
In regards to claim 13, it is rejected on the same grounds as claim 5.
In regards to claim 14, it is rejected on the same grounds as claim 4.
In regards to claim 15, it is rejected on the same grounds as claim 6.
In regards to claim 16, it is rejected on the same grounds as claim 2.
In regards to claim 17, it is rejected on the same grounds as claim 9.
In regards to claim 18, it is rejected on the same grounds as claim 10.
In regards to claim 19, it is rejected on the same grounds as claim 3.
In regards to claim 20, it is rejected on the same grounds as claim 8.
Conclusion
Applicant's amendment necessitated the new ground(s) of rejection presented in this Office action. Accordingly, THIS ACTION IS MADE FINAL. See MPEP § 706.07(a). Applicant is reminded of the extension of time policy as set forth in 37 CFR 1.136(a).
A shortened statutory period for reply to this final action is set to expire THREE MONTHS from the mailing date of this action. In the event a first reply is filed within TWO MONTHS of the mailing date of this final action and the advisory action is not mailed until after the end of the THREE-MONTH shortened statutory period, then the shortened statutory period will expire on the date the advisory action is mailed, and any extension fee pursuant to 37 CFR 1.136(a) will be calculated from the mailing date of the advisory action. In no event, however, will the statutory period for reply expire later than SIX MONTHS from the date of this final action.
Any inquiry concerning this communication or earlier communications should be directed to Examiner Ayal Sharon, whose telephone number is (571) 272-5614, and fax number is (571) 273-1794. The Examiner can normally be reached from Monday to Friday between 9 AM and 6 PM. If attempts to reach the examiner by telephone are unsuccessful, the examiner’s supervisor, SPE Christine Behncke can be reached at (571) 272-8103 or at christine.behncke@uspto.gov. The fax 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.
Sincerely,
/Ayal I. Sharon/
Examiner, Art Unit 3695
September 5, 2026
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