SHIELD is a system that automates claims medical adjudication, detects potential fraud, waste and abuse, and justifies denials. It combines rules-based and machine learning models to optimize insurers’ health claims outcomes.

Unlike other rules-based engines, SHIELD comes with standard rule sets for specific geographies, but also gives insurers the flexibility to modify rules or add their own. SHIELD not only detects potential fraud but can also approve or reject a claim, based on medical rules and machine learning models and automates decisions.

Medical claims are typically large volume and high frequency, which means they would need teams of experts to investigate them properly, resulting in higher costs and increased turnaround times. This is the area where SHIELD can add value by automating the medical adjudication of claims, shortening transaction times and achieving cost containment in insurers claims’ operations.