Health Claims Management

Business Rules Engine in Healthcare Claims Automation

Automate Claims Processing and Identify Fraudulent Claims

Business Rules Engine helps in the configuration of business rules by the business users to enable automation of claim processing and identification of fraudulent/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 Rules Engine’, that is fully capable of configuring business rules for straight through processing and identification of suspect or fraudulent claims.
Business Rules 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.

Functionalities

Explore the functionalities of Business Rules Engine Module and achieve operational excellence by identifying fraudulent claims

Configure/modify/edit rules

Group and sequence rules

Configure execution and evaluative rules

Identify and escalate suspect claims for investigation

Capabilities

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

Automated workflow (including Straight-through processing)

Automatically identifying suspect (fraud or abuse) cases based on scenarios configured

Configure rules to run at Pre-auth level or Claims level

Define rules to run on historic claims or fresh claims

Attach status and action for execution

Assign/modify score to a rule

Straight-through processing (STP) Rules

Value Proposition

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

  • Centralized Knowledge Base

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

  • Integrate with Applications

    Provide ways to edit and manage rules to provide immediate feedback and validations to existing application

  • Achieve Straight-through Processing (STP)

    Enable Straight Through Processing (STP) of health insurance claims based on business rules

  • 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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Interested to learn more about how Business Rule Engine can help you in identifying claim fraud?

Request Demo

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