Abstract: A trained predictive server is provided for determining that a diagnosis and treatment plan is inaccurate. The trained predictive server includes a processor configured to receive a set of prior authorization (PA) data associated with a medical claim for a patient, and determine that the set of PA data indicates that the medical claim is associated with a qualifying critical illness. The processor is further configured to extract component data from the set of PA data, and apply the extracted component data to a trained predictive model associated with the qualifying critical illness to determine whether the medical claim is associated with an inaccurate diagnosis and treatment plan. Upon determining that the medical claim is associated with an inaccurate diagnosis and treatment plan, the processor is configured to generate a request for a consulting review of the diagnosis and treatment plan using the set of PA data.

Abstract: The present invention is embodied in a system and method for managing and controlling accounts with generated profile information. The system includes a data generator, a database and a search agent. The data generator generates, collects and processes data about potential buyers and generates customer profiles. Data can be collected and processed by any suitable means for generating profiles, such as a data gathering session. In one example, a potential buyer can be provided with an interactive browsing environment and allowed to select information related to products or services. The search agent is used to create the database, which comprises buyers having organized profiles that define specific criteria. A profile of the buyer can be created by inferring criteria desired by the buyer based on the interactive browsing and the selections made by the buyer.