Generative AI Claim Processing System, LLM Integration, Patent Application
Summary
The USPTO published patent application US20260099883A1, filed April 9, 2025, covering a generative AI-based system for claims data processing and evaluation. The system generates prompt data from parsed standard operating procedures and rules, uses a large language model to produce first and second rule sets, extracts non-adjudicated claims data with corresponding edit codes, and validates claims against the second rule set to generate resolution recommendations. The invention appears directed toward automating insurance or healthcare claims adjudication workflows.
What changed
The USPTO published a patent application covering a generative AI system that processes claims data using large language models. The system parses standard operating procedures and rules to generate prompts for an LLM, which produces rule sets that are then used to validate non-adjudicated claims and corresponding edit codes, outputting recommendations for claim resolution.
For parties in insurance, healthcare administration, or financial services technology, this application signals growing patent activity around AI-driven claims automation. While the application does not create immediate compliance obligations, organizations developing or evaluating AI-based claims processing workflows should monitor USPTO issuance of this patent family for potential licensing considerations or freedom-to-operate analysis.
Archived snapshot
Apr 20, 2026GovPing captured this document from the original source. If the source has since changed or been removed, this is the text as it existed at that time.
GENERATIVE AI-BASED SYSTEM AND METHOD FOR CLAIM DATA PROCESSING AND EVALUATION
Application US20260099883A1 Kind: A1 Apr 09, 2026
Inventors
Debojyoti Hazra, Latoya James, Mohamed Abdul Sattar, Guruprasad Krishnadoss, Jigar Ashok Parikh, Chandra Sekhar Dasika, Muniraju Bhadrappa, Milind Tilak, Richa Chaudhary
Abstract
A system and method for Gen AI based claim data processing and evaluation is provided. The present invention enables generating prompt data by processing parsed standard operation procedure data and rules data associated with a first set of pre-defined rules. The prompt data is provided as a first prompt data to a Large Language Model (LLM) to generate a set of first rules. Set of first rules is provided along with output generation instructions as a second prompt data to the LLM to generate a set of second rules. Non-adjudicated claims data is extracted along with corresponding non-automated edit codes for evaluation. An output is generated in the form of recommendations by validating non-adjudicated claims data and corresponding non-automated edit codes based on a comparison with set of second rules. The recommendations are provided for resolving the non-adjudicated claims data.
CPC Classifications
G06Q 40/08 G06F 40/205 G06N 3/042 G06N 3/0475 G06N 3/10 G06F 40/103
Filing Date
2025-04-09
Application No.
19174284
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