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 18):
The system of  claim 10 , wherein determining whether or not the prior tier within the prior formulary is an improvement over the initial tear within the current formulary comprises:\n determining whether adjudicating the current claim at the prior tier within the prior formulary is less costly to the member than adjudicating the current claim at the initial tier within the current formulary; if it is determined that adjudicating the current claim at the prior tier is less costly to the member than adjudicating the current claim at the initial tier, determining that the prior tier is an improvement over the initial tier; and, if it is not determined that adjudicating the current claim at the prior tier is less costly to the member than adjudicating the current claim at the initial tier, determining that the prior tier is not an improvement over the initial tier.

Metadata:
- Claim Count in Document: 4.0
- Percentile: 100.0
- Lexical Diversity: 2.28986
- Patent Class: 705.0
- Transitional Phrase Type: none
- Component Type: 0
- Foreign Priority: False
- Related Applications: ['12913685', '10357917', '10608265', '11693170', '13780073']

Analysis Scores:
- 35 USC 101 Eligibility (BERT): 0.1334638534212294
- 35 USC 102 Novelty (BERT): 0.5328776164614442
- Combined Prediction Score: 0.1734052297252509
- Mean Citation Score: 233.802292
- Max Citation Score: 352.023
- Similarity Product: 196.0311681557894

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