Configurable Claims Review Engine

A claims review engine which will allow the scheme operator to define the various conditions for the automatic acceptance/rejection of a claim is deemed necessary to make the claim review processes more efficient. It would build on the current automated checks applied on claims during submission, to include conditionality based on additional factors around beneficiary, product, services, and item definition. This engine is expected to allow users to enter multiple 'rules,' which would have various trigger conditions, but would have an action of either rejecting, accepting or flagging (fully/partially) claims. The rules should take into additional factors such as the diagnosis entered in a claim, the relationships between medical services and items claimed, including quantities etc - the incorporation of these additional factors in the 'rules engine' might require that some additional parameters to be added to the beneficiary, product, services, and items definitions. It is envisioned that the rules engine would have a user interface similar to the ones used by email management software such as MS Outlook for defining rules.

Example

An example of potential rules

• If diagnosis is B12, then the service codes 100 to 150 are not allowed. Reject other services.

• If service code 112 is claimed, only item codes 200 to 210 are allowed. Reject if other items are.

• Service code 225 and 325 cannot be claimed together. Reject both services.

So, if a claim has the following details:

Service 1 would be rejected, and the remaining services and items would be accepted and sent forward for manual review.