PATENT CLAIM ANALYSIS

Application Number: 16428291
Application Type: Utility
Filing Date: 2019-05
Publication Date: 2019-09
Patent Classification: ["705", "002000"]

Abstract:
Systems and methods for overriding claim denials and approvals are provided that determine that a current claim will be denied and search the purchasing member's claim history for previously approved claims that match the current claim. If a matching claim is found and is dated within a certain predetermined window of time, the current claim is approved. Additionally, when it is determined that a current claim will be approved at a high tier level the member's claim history is searched for a previously approved claim that matches the current claim and a formulary crosswalk analysis is performed. If a matching claim with a lower tier level is found in the member's claim history or the crosswalk analysis determines that a lower tier level is available, the current claim is processed using the lower tier. Claims overridden are digitally stamped for reporting purposes and for subsequent claim matching.

Claim (Index 1):
A method comprising executing machine-readable instructions, on at least one hardware processor, to:\n receive a claim adjudication request from an originating system over at least one network, wherein the claim adjudication request comprises a current claim identifying a healthcare plan and a member of said healthcare plan; determine whether adjudicating the current claim would result in a denial of the current claim or an allowance of the current claim at an initial tier; if it is determined that adjudicating the current claim would result in a prospective denial of the current claim,\n retrieve historical claim data from a non-transitory computer-readable medium, \n search the historical claim data to determine whether a prior claim, matching the current claim, was allowed, \n when it is determined that a prior claim, matching the current claim, was allowed, override the prospective denial of the current claim, and, \n when it is not determined that a prior claim, matching the current claim, was allowed, do not override the prospective denial of the current claim; \n if it is determined that adjudicating the current claim would result in an allowance of the current claim at an initial tier within a current formulary,\n search the historical claim data to determine whether a prior claim, matching the current claim, was allowed at a prior tier within a prior formulary that is different than the current formulary, and, \n when it is determined that a prior claim, matching the current claim, was allowed at a prior tier,\n access a tier mapping to determine whether or not the prior tier within the prior formulary is an improvement over the initial tier within the current formulary, wherein the tier mapping maps a plurality of tiers in the prior formulary to a plurality of tiers in the current formulary, \n when it is determined that the prior tier is an improvement over the initial tier, adjudicate the allowance of the current claim based on the prior tier, and, \n when it is determined that the prior tier is not an improvement over the initial tier, adjudicate the allowance of the current claim at the initial tier; and \n \n transmit a result of the adjudication to the originating system over the at least one network.

Metadata:
- Claim Count in Document: 4.0
- Percentile: 100.0
- Lexical Diversity: 2.28986
- Patent Class: 705.0
- Transitional Phrase Type: open
- Component Type: 1
- Foreign Priority: False
- Related Applications: ['12913685', '10357917', '10608265', '11693170', '13780073']

Analysis Scores:
- 35 USC 101 Eligibility (BERT): 0.1200005101483179
- 35 USC 102 Novelty (BERT): 0.528292950010025
- Combined Prediction Score: 0.1608297541344887
- Mean Citation Score: 233.802292
- Max Citation Score: 352.023
- Similarity Product: 248.5220588243008

Labels:
- Claim Label 101: 1
- Claim Label 102: 1
- Claim Label 103: 1
- Claim Label 112: 1
- Combined Label: 1
- Label 101 Adjusted: 1

Dataset: test