Medical Rule Engine
Health Insurance Claims Decision Support

Our Medical Rule Engine enables insurers reduce the costs of health insurance claims and improve the quality of their claims adjudication process. It is an expert system containing millions of medical rules and rule edits that can be used to evaluate claims for plausibility and medical correctness. It also detects incorrect billing and potential fraud and abuse. It works either stand-alone or can be integrated with any core insurance back-office system to automate and improve the quality of claim adjudication.

Key benefits
  •  Automated and consistent claims adjudication
  •  Lower health insurance claims costs
  •  Reduction of risk caused by fraudulent actions
  •  Improvement of claims turn-around-times and customer satisfaction
Key features
  • Rule Editing Platform for creation, storage and maintenance of the medical knowledge base (rules/edits)
  • Easy customization to the specific claims practices and rules of the customer
  • Ability to deploy in various aspects of the claims process e.g. back-office claims/authorizations, electronic claims/authorizations as well as electronic prescriptions
  • Ability to check correctness of diagnosis, procedures and drag codes
  • Ability to manage complex medical rules e.g. length of stay and drug refill
  • Stand-alone operation as well as Integration with any core insurance back-office system