Ontology and rule based adjudication

A method for claim adjudication comprising:

• generating an ontology corresponding a claim adjudication request, using an ontology based technique;
• processing the claim adjudication request, based on the ontology, to provide an ontology based inference;
• identifying a predefined rule for processing the claim adjudication request;
• processing the claim adjudication request, based on the predefined rule, to provide a rule based inference;
• ascertaining whether the ontology based inference conflicts with the rule based inference, a conflict being detected when the ontology based inference and the rule based inference indicate conflicting actions;
• when the conflict is detected, selecting a predefined criteria for resolving the conflict, the predefined criteria comprising rules to select one of the ontology based inference and the rule based inference to maximize a probability of accurately processing the claim adjudication request in case the conflict is detected;
• and
• implementing the predefined criteria to provide a final outcome indicative of how to resolve the conflict.

A non-transitory computer readable medium including machine readable instructions that are executable by a processor to:

• generate an ontology corresponding a claim adjudication request, using an ontology based technique;
• process the claim adjudication request, based on the ontology, to provide an ontology based inference;
• identify a predefined rule for processing the claim adjudication request;
• process the claim adjudication request, based on the identified rule, to provide a rule based inference;
• ascertain whether the ontology based inference conflicts with the rule based inference, a conflict being detected when the ontology based inference and the rule based inference indicate conflicting actions;
• when the conflict is detected, select a predefined criteria for resolving the conflict, the predefined criteria comprising rules to select one of the ontology based inference and the rule based inference to maximize a probability of accurately processing the claim adjudication request in case the conflict is detected;
• and
• implement the predefined criteria to provide a final outcome indicative of how to resolve the conflict.