Abstract: The Use Determination Risk Coverage Datastructure for On-Demand and Increased Efficiency Coverage Detection and Rebalancing Apparatuses, Methods and Systems (“UDRCD”) transforms coverage enrollment request, event signal, ACGG request, search request inputs via UDRCD components into coverage enrollment response, add-in recommendation, ACGG response, search response outputs. A set of clinical conditions is determined. A set of treatments is determined for each clinical condition. Treatment paths data that specifies a set of treatment paths, wherein each treatment path comprises an ordered subset of treatments, is determined for each clinical condition. Providers are determined for each treatment. Practice patterns data that specifies, for each clinical condition treated by each provider, how likely the respective provider is to utilize each of the treatment paths is determined.

Abstract: A plan authoring tool can receive user input describing parameters of benefits of a benefit plan. The plan authoring tool can convert the user input into a machine structured plan description (MSPD) that defines the benefit plan. The MSPD can be used by a plan documentation generator to generate one or more plan documents that explain the benefits and/or indicate how to manually adjudicate claims submitted in association with the benefit plan. The MSPD can also be used to automatically adjudicate claims. Plan analysis tools can be used to evaluate an MSPD to validate a new or edited benefit plan and/or provide user feedback on the benefit plan so that users, if desired, can revise the MSPD via the plan authoring tool.

Abstract: A claim adjudication system including an automatic adjudication pipeline that uses pipeline rules to automatically adjudicate a claim associated with a benefit plan at one or more stages. The automatic adjudication pipeline can redirect the claim to a user interface for manual review when a pipeline rule associated with a manual review condition is triggered. The user interface can present information about the claim relevant to the manual review condition in an integrated format, including highlighting the reasons for the manual review. A user can evaluate the claim in the user interface and provide user input that addresses the manual review condition, and the claim can be routed back to the automatic adjudication pipeline. The user input can also be used as training data for machine learning to adjust pipeline rules that are used to automatically process claims and to redirect future claims for manual review.

Abstract: A claim adjudication system including an automatic adjudication pipeline that uses pipeline rules to automatically adjudicate a claim associated with a benefit plan at one or more stages. The automatic adjudication pipeline can redirect the claim to a user interface for manual review when a pipeline rule associated with a manual review condition is triggered. The user interface can present information about the claim relevant to the manual review condition in an integrated format, including highlighting the reasons for the manual review. A user can evaluate the claim in the user interface and provide user input that addresses the manual review condition, and the claim can be routed back to the automatic adjudication pipeline. The user input can also be used as training data for machine learning to adjust pipeline rules that are used to automatically process claims and to redirect future claims for manual review.

Abstract: A plan authoring tool can receive user input describing parameters of benefits of a benefit plan. The plan authoring tool can convert the user input into a machine structured plan description (MSPD) that defines the benefit plan. The MSPD can be used by a plan documentation generator to generate one or more plan documents that explain the benefits and/or indicate how to manually adjudicate claims submitted in association with the benefit plan. The MSPD can also be used to automatically adjudicate claims. Plan analysis tools can be used to evaluate an MSPD to validate a new or edited benefit plan and/or provide user feedback on the benefit plan so that users, if desired, can revise the MSPD via the plan authoring tool.

Abstract: A plan authoring tool can receive user input describing parameters of benefits of a benefit plan. The plan authoring tool can convert the user input into a machine structured plan description (MSPD) that defines the benefit plan. The MSPD can be used by a plan documentation generator to generate one or more plan documents that explain the benefits and/or indicate how to manually adjudicate claims submitted in association with the benefit plan. The MSPD can also be used to automatically adjudicate claims. Plan analysis tools can be used to evaluate an MSPD to validate a new or edited benefit plan and/or provide user feedback on the benefit plan so that users, if desired, can revise the MSPD via the plan authoring tool.

Abstract: A claim adjudication system including an automatic adjudication pipeline that uses pipeline rules to automatically adjudicate a claim associated with a benefit plan at one or more stages. The automatic adjudication pipeline can redirect the claim to a user interface for manual review when a pipeline rule associated with a manual review condition is triggered. The user interface can present information about the claim relevant to the manual review condition in an integrated format, including highlighting the reasons for the manual review. A user can evaluate the claim in the user interface and provide user input that addresses the manual review condition, and the claim can be routed back to the automatic adjudication pipeline. The user input can also be used as training data for machine learning to adjust pipeline rules that are used to automatically process claims and to redirect future claims for manual review.

Abstract: A plan authoring tool can receive user input describing parameters of benefits of a benefit plan. The plan authoring tool can convert the user input into a machine structured plan description (MSPD) that defines the benefit plan. The MSPD can be used by a plan documentation generator to generate one or more plan documents that explain the benefits and/or indicate how to manually adjudicate claims submitted in association with the benefit plan. The MSPD can also be used to automatically adjudicate claims. Plan analysis tools can be used to evaluate an MSPD to validate a new or edited benefit plan and/or provide user feedback on the benefit plan so that users, if desired, can revise the MSPD via the plan authoring tool.

Abstract: A plan authoring tool can receive user input describing parameters of benefits of a benefit plan. The plan authoring tool can convert the user input into a machine structured plan description (MSPD) that defines the benefit plan. The MSPD can be used by a plan documentation generator to generate one or more plan documents that explain the benefits and/or indicate how to manually adjudicate claims submitted in association with the benefit plan. The MSPD can also be used to automatically adjudicate claims. Plan analysis tools can be used to evaluate an MSPD to validate a new or edited benefit plan and/or provide user feedback on the benefit plan so that users, if desired, can revise the MSPD via the plan authoring tool.

Abstract: A plan authoring tool can receive user input describing parameters of benefits of a benefit plan. The plan authoring tool can convert the user input into a machine structured plan description (MSPD) that defines the benefit plan. The MSPD can be used by a plan documentation generator to generate one or more plan documents that explain the benefits and/or indicate how to manually adjudicate claims submitted in association with the benefit plan. The MSPD can also be used to automatically adjudicate claims. Plan analysis tools can be used to evaluate an MSPD to validate a new or edited benefit plan and/or provide user feedback on the benefit plan so that users, if desired, can revise the MSPD via the plan authoring tool.

Abstract: A plan authoring tool can receive user input describing parameters of benefits of a benefit plan. The plan authoring tool can convert the user input into a machine structured plan description (MSPD) that defines the benefit plan. The MSPD can be used by a plan documentation generator to generate one or more plan documents that explain the benefits and/or indicate how to manually adjudicate claims submitted in association with the benefit plan. The MSPD can also be used to automatically adjudicate claims. Plan analysis tools can be used to evaluate an MSPD to validate a new or edited benefit plan and/or provide user feedback on the benefit plan so that users, if desired, can revise the MSPD via the plan authoring tool.