SHIELD - Software for Health Insurance Eligibility Detection

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.

• Medical rule engine,
• Outlier rule engine
• Supervised machine learning model
• Unsupervised machine learning model
• REST API

SHIELD optimizes and automates medical claims processing and lets you respond more quickly to claimants and resolve legitimate claims faster, leading to greater customer satisfaction.

More specifically, SHIELD provides:

- Increased capacity to investigate and detect anomalies and inconsistencies

- Enhanced SLA compliance

- Improved turnaround times and customer experience

- Easy integration with existing processes and systems

- Lower claim costs