Health Claims Management

Business Rule Engine

Business Rule Engine to Automate Insurance Operations and Identify Fraudulent Claims

Business Rule Engine helps in the configuration of business rules by business users to help automate underwriting and claims processes, facilitate Straight-through-Processing (STP) and seamlessly identify fraudulent and suspect claims

Overview

ClaimsLive Health, our state-of-the-art and customizable technology platform for end-to-end digital claims management and fraud detection for health insurance offers an exclusive ‘Business Rule Engine’, that is fully capable of configuring business rules for straight-through-processing and identification of suspect or fraudulent claims.
 
The dynamic rule engine strikingly differentiates itself from other business rule engines by providing business users with an intuitive user interface (UI) for configuration of business rules. It reduces the complexity of the underwriting process by automating key underwriting tasks and improves the quality of risk assessment by constantly analyzing information and highlighting cases that need underwriter intervention.
 
Business Rule Engine helps tackle the intricacy of managing a large amount of complex claims business logic calculations and manages decision processes using pre-defined logic to determine outcomes. The versatile engine replaces manual inspection of claims with automated claims processing, triggers automated workflows and detects claims fraud by defining rules to identify claims that are valid and claims that are fraudulent.
 

Capabilities

Leverage the enhanced capabilities of the Business Rule Engine Module to help increase operational efficiency

Inbuilt nested conditions

Rules for triggering workflow

Configuration of evaluation rules and execution rules

Configure rules to run at various stages of proposal

Configure straight-through-processing rules and fraud detection rules

Define rules to run on historic claims or fresh transactions

Rule grouping for score card configuration

Test bed for testing rules

Automatic identification of suspect/fraud cases

Guided form for creation of business rules

Supports multiple lines of business

Rule sequencing for execution

Value Proposition

Business Rule Engine Module comes with a range of benefits to help automate claims processing and identify fraudulent claims

  • Automate Underwriting Processes

    Enhance the efficiency of underwriters to make quick and informed decisions

  • Easily Integrate with External Applications

    Expose APIs for consumption by external systems to provide immediate feedback and validations to existing application

  • Achieve Straight Through Processing (STP)

    Underwriting proposals and claims, based on business rules, get automatically issued while the remaining are flagged as non-compliant

  • Reduce Dependency on IT

    Rules based automation without coding enables business users to define, test, implement and change business rules quickly

  • Automate Claims Processing and Detect Fraud Claims

    Intelligent automation acts like a powerful deterrent to claims fraud by flagging fraudulent proposals and suspicious claims

  • Centralized Knowledge Base

    By using rules, create a repository of knowledge which is executable

  • Issue1 Real Time Quotes/Policies

    Instantly generate quotes and issue policies. Reduce load on your core insurance system

  • Provide Quick Turn Around Time (TAT)

    Delight your customers by providing quicker turnaround times for policy issuance, renewals, endorsements

  • Ensure Greater Flexibility

    Allows insurance companies to configure different privileges for pricing, underwriting and operations to
    different intermediaries

  • Gain Better Oversight

    Take complete control over your distribution network with configurable levels of pricing and underwriting
    privileges

  • Increase Transparency

    Manage complex commission structures and make payments online

  • Be Eco-friendly

    Help the environment by enabling end-to-end paperless process for policy issuance

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