Generative ai-based system and method for claim data processing and evaluation

A method for Generative Artificial Intelligence (Gen AI) based claim data processing and evaluation, the method is implemented by a processor executing instructions stored in a memory, the method comprises:

• generating prompt data by processing parsed Standard Operation Procedure (SOP) data and rules data associated with a first set of pre-defined rules;
• providing the prompt data as a first prompt data to a Large Language Model (LLM) to generate set of first rules;
• providing the set of first rules along with one or more output generation instructions as a second prompt data to the LLM to generate a set of second rules, and wherein the set of second rules is employed for evaluating one or more non-adjudicated claims data, the non-adjudicated claims data is extracted along with corresponding one or more non-automated edit codes from an adjudication unit for evaluation;
• and
• generating an output in the form of one or more recommendations by validating the non-adjudicated claims data and the corresponding non-automated edit codes based on a comparison with the set of second rules, wherein the recommendations are provided to the adjudication unit for resolving the non-adjudicated claims data.

A computer program product comprising:

• a non-transitory computer-readable medium having computer program code stored thereon, the computer-readable program code comprising instructions that, when executed by a processor, causes the processor to:
• generate prompt data by processing parsed Standard Operation Procedure (SOP) data and rules data associated with a first set of pre-defined rules;
• provide the prompt data as a first prompt data to a Large Language Model (LLM) to generate a set of first rules;
• provide the set of first rules along with one or more output generation instructions as a second prompt data to the LLM to generate a set of second rules, wherein the set of second rules is employed for evaluating one or more non-adjudicated claims data, and wherein the non-adjudicated claims data is extracted along with corresponding one or more non-automated edit codes from an adjudication unit for evaluation;
• and
• generate an output in the form of one or more recommendations by validating the non-adjudicated claim data and the corresponding non-automated edit codes based on a comparison with the set of second rules, wherein the recommendations are provided to the adjudication unit for resolving the non-adjudicated claims data.