SMAART (Sophisticated Monitoring and Analysis of Risk Tool

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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

Key Features

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

Key Benefits

  • 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

Product/Service details