Intelligent filtering of transactions over a network using learned rules

A system for filtering transactions over a network, the system comprising:

• a processor;
• and
• a memory device that stores program code structured to cause the processor to:
• retrieve, over the network, a transaction request;
• access a model configured to predict a likelihood associated with automatic adjudications of transactions;
• based at least on the transaction request and the model, determine a likelihood that the transaction request can be adjudicated automatically;
• if the likelihood that the transaction request can be adjudicated automatically is above a threshold, perform one of:
• generating an indication that at least a portion of the transaction request can be adjudicated automatically, or
• generating an automatic adjudication indicating whether the transaction request should be approved;
• and
• in response to generating the indication or the automatic adjudication, forward the transaction request and one of the indication or the automatic adjudication over the network to an endpoint associated with the transaction request.

A system for generating a machine-learning model to identify prior authorization requests that meet a threshold for further processing by a transaction approval system, the system comprising:

• a processor;
• and
• a memory device that stores program code structured to cause the processor to:
• retrieve prior authorization training data corresponding to tracked prior authorizations;
• generate a plurality of vectors based at least on one or more of the prior authorization training data, a prior authorization history, a prescription history, or a data source providing clinical data;
• generate combined prior authorization vectors based at least on the plurality of vectors;
• and
• generate a recommendation model using a supervised machine-learning algorithm based at least on the combined prior authorization vectors, the recommendation model configured to identify a likelihood that a retrieval of clinical data will satisfy a set of rules configured for the least one of a payer or medication identified in a transaction request.