# US 2019/0244121 A1 · Ontology and rule based adjudication > Agents: this data is available as JSON from the patentgrep API and MCP server — see https://patentgrep.com/llms.txt - Number: US 2019/0244121 A1 - Document ID: US20190244121A1 - Status: Published application - Kind: A1 - Application number: 16/037,807 - Filed: 2018-07-17 - Published: 2019-08-08 - Earliest claimed: 2018-02-02 - Assignees: Accenture Global Solutions Limited - Applicants: Accenture Global Solutions Limited - Inventors: Chung-Sheng LI; Guanglei Xiong; Mohammad Ghorbani; Emmanuel Munguia Tapia; Sukryool Kang; Benjamin Nathan Grosof; Ashish Jain; Colin Connors - Web page: https://patentgrep.com/patent/US20190244121A1 ## CPC - G06N 5/046: Forward inferencing; Production systems - G06N 5/02: Knowledge representation; Symbolic representation - G06N 5/043: Distributed expert systems; Blackboards - G06Q 40/08: Insurance - G16H 40/20: for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms - G16H 50/20: for computer-aided diagnosis, e.g. based on medical expert systems - G06N: COMPUTING ARRANGEMENTS BASED ON SPECIFIC COMPUTATIONAL MODELS - G06Q: INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR - G16H: HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA ## Abstract In an example, an ontology analyzer may generate an ontology, based on a claim adjudication request. The claim adjudication request may be processed, based on the ontology to provide an ontology based inference. A rule based analyzer may identify a predefined rule corresponding to the claim adjudication request and process the request, based on the predefined rule. A conflict resolver may resolve a conflict which may occur between the ontology based inference and the rule based inference. When a conflict is detected, a predefined criteria may be selected 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 of a conflict. ## Claims ### Claim 1 An integrated ontology and rule based inference system comprising: a processor; an ontology analyzer coupled to the processor, the ontology analyzer to, generate an ontology corresponding to a claim adjudication request, using an ontology based technique; and process the claim adjudication request, based on the ontology, to provide an ontology based inference: a rule based analyzer coupled to the processor, the rule based analyzer to: identify a predefined rule for processing the claim adjudication request; and process the claim adjudication request, based on the predefined rule, to provide a rule based inference; and a conflict resolver coupled to the processor and in communication with the ontology analyzer and the rule based analyzer, the conflict resolver to, 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. ### Claim 2 (depends on 1) The integrated ontology and rule based inference system as claimed in claim 1, wherein the system further comprises a receiver to: receive the claim adjudication request; and extract claim data from the claim adjudication request to assist in at least one of generating the ontology and identifying the predefined rule. ### Claim 3 (depends on 1) The integrated ontology and rule based inference system as claimed in claim 1, wherein the ontology analyzer is to associate a first confidence score with the ontology based inference and the rule based analyzer is to associate a second confidence score with the rule based inference. ### Claim 4 (depends on 3) The integrated ontology and rule based inference system as claimed in claim 3, wherein the predefined criteria to select an inference as the final outcome includes at least one of: selecting the inference with a higher confidence score from among the ontology based inference and the rule based inference; implementing a statistical technique to identify a preferred inference from among the ontology based inference and the rule based inference; and selecting the inference from among the ontology based inference and the rule based inference, based on a selection rule indicating the inference to be selected, in case the conflict is detected. ### Claim 5 (depends on 1) The integrated ontology and rule based inference system as claimed in claim 1, wherein the claim adjudication request comprises at least one of user data and policy data, the user data comprising details pertaining to a user and the policy data comprising details pertaining to a policy corresponding to the claim adjudication request. ### Claim 6 (depends on 1) The integrated ontology and rule based inference system as claimed in claim 1, wherein the conflict resolver comprises: a selection criteria determiner to select one or more selection criteria, which are applicable in order to resolve the conflict between the ontology based inference and the rule based inference; and a classifier to select the predefined criteria from the one or more criteria, based on historical data. ### Claim 7 (depends on 1) The integrated ontology and rule based inference system as claimed in claim 1, wherein the conflict resolver further comprises an outcome monitor to monitor and evaluate the final outcome to perform self learning of the conflict resolver. ### Claim 8 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. ### Claim 9 (depends on 8) The method as claimed in claim 8, wherein the method further comprises: receiving the claim adjudication request; and extracting claim data from the claim adjudication request to assist in at least one of generating the ontology and identifying the predefined rule. ### Claim 10 (depends on 8) The method as claimed in claim 8, wherein the method further comprises associating a first confidence score with the ontology based inference and associating a second confidence score with the rule based inference. ### Claim 11 (depends on 10) The method as claimed in claim 10, wherein the predefined criteria to select an inference as the final outcome includes at least one of: selecting the inference with a higher confidence score from among the ontology based inference and the rule based inference; implementing a statistical technique to identify a preferred inference from among the ontology based inference and the rule based inference; and selecting the inference from among the ontology based inference and the rule based inference, based on a selection rule indicating the inference to be selected, when the conflict is detected. ### Claim 12 (depends on 8) The method as claimed in claim 8, wherein the claim adjudication request comprises at least one of user data and policy data, the user data comprising details pertaining to a user and the policy data comprising details pertaining to a policy corresponding to the claim adjudication request. ### Claim 13 (depends on 8) The method as claimed in claim 8, wherein selecting the predefined criteria comprises receiving one or more selection criteria, which are applicable in order to resolve the conflict between the ontology based inference and the rule based inference; and selecting the predefined criteria from the one or more criteria, based on historical data. ### Claim 14 (depends on 8) The method as claimed in claim 8, wherein the method further comprises evaluating the final outcome to perform self learning for resolving conflicts. ### Claim 15 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. ### Claim 16 (depends on 15) The non-transitory computer readable medium as claimed in claim 15, wherein the processor is to: receive the claim adjudication request; and extract claim data from the claim adjudication request to assist in at least one of generating the ontology and identifying the predefined rule. ### Claim 17 (depends on 15) The non-transitory computer readable medium as claimed in claim 15, wherein the processor is to associate a first confidence score with the ontology based inference and associating a second confidence score with the rule based inference. ### Claim 18 (depends on 15) The non-transitory computer readable medium as claimed in claim 15, wherein the predefined criteria to select an inference as the final outcome includes at least one of: selecting the inference with a higher confidence score from among the ontology based inference and the rule based inference; implementing a statistical technique to identify a preferred inference from among the ontology based inference and the rule based inference; and selecting the inference from among the ontology based inference and the rule based inference, based on a selection rule indicating the inference to be selected, when the conflict is detected. ### Claim 19 (depends on 15) The non-transitory computer readable medium as claimed in claim 15, wherein the claim adjudication request comprises at least one of user data and policy data, the user data comprising details pertaining to a user and the policy data comprising details pertaining to a policy corresponding to the claim adjudication request. ### Claim 20 (depends on 15) The non-transitory computer readable medium as claimed in claim 15, wherein to select the predefined criteria the processor is to: receive one or more selection criteria, which are applicable in order to resolve the conflict between the ontology based inference and the rule based inference; and select the predefined criteria from the one or more criteria, based on historical data.