Medical Rule Engine

Medical Rule Engine is a claims management service that automatically checks invoices for medical plausibility and accuracy.

Itenables insurers to reduce the costs of health insurance claims and improve turn-around-times. It comprises 2.5 million rules to check for consistency of a combination between pharmaceuticals, medical procedures, diagnosis, age and gender based on ICD10 and CPT 2012 coding standards.

It detects potential fraud or abuse.

It can be offered either as stand-alone or integrated with any core insurance back-office system

Rule Editing Platform for creation, storage and maintenance of the medical knowledge base (rules/edits)

• Easy customisation to the client’s specific claims practices and rules
• Ability to deploy in various aspects of the claims process, e.g. back-office claims/ authorisations, electronic claims/authorisations 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

• Reduced claims costs
• Detection and prevention of incorrect billing and fraud or abuse
• Transparency and consistency in claims adjudication
• Reduced costs and turn-around time of claim reviews