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Insurance Claim System

Key Offering

  • Claim pipeline management
  • Claim submission process
  • Claim Approval process
  • Claim approval STP based on rule engine
  • Fraud detection (early warning system)
  • Cost optimization

End-to-end Claim Processing System

A high-end claim-centric processing system that optimizes operational excellence and fast-tracks claim management. It provides cutting-edge features for efficient management of various business functions, from claim pipeline management, claim submission to claim approval process, fraud detection, cost optimization and beyond.

Few points on the objective client wanted to achieve

  • Digitize and automate medical claim submission and approval process.
  • Real-time Monitoring & Control of the operations.
  • Live Communication & improved quality of services (for Policy Holders)
  • Automation of the manual, far-reaching, critical process of Medical Services.

Key solution elements (business functions)

  • Medical Service Provider- For claim submission
  • Claim Department – For Claim review and approval function
  • Policy Holder – To Check and see limits
  • Rule Engine – To support auto Approval/Rejection of claims based on Knowledge Base.
  • Administration – For services mapping and configurations

Key benefits achieved through this solution (qualitative)

  • Increase interaction with stakeholders
  • Improve provider, customer experience
  • Enable Decision Makers to:
    1. View loss ratio against the particular contract
    2. Take necessary action against any unpredicted & unusual activity
    3. Know the liabilities and resource planning according to business directions
    4. Look at forecast upcoming corporate & operational challenges
  • Management dashboards to enable them for developing trends of medical services and diagnosis.

Any KPIs / measures that could quantify the benefits (quantitative)

    1. Almost half a million claim processing every month through the claim system.
    2. All medicine claims which are approx. 10-12,000 / day are processed by rule engine taking the auto decision of accepting or rejection based on certain medical rules, patient history, and medicine prescribed by consulting doctor. This gives an average of 5% saving to insurance companies overall for medical claims.
    3. 60% of claims processed directly by the system based on pre-defined rules.
    4. SLA time between claim submission and decision time is:
      1. less than 2 minutes for pharmacy claims
      2. within 10 minutes for hospitalization claims