Incedo_Insuranceplatform

Inspiration

Post the pandemic, the medi-claims industry is facing a huge backlog on pending claim applications. There has also been an increase in fraudulent claim requests due to lack of resources and AI technology to detect fraud patterns. Due to this there been huge losses faced by Insurance companies and vendors alike.

What it does

Our application boasts of Straight through processing of claim requests in case of no previous duplicate claims or suspicious news items related to claim requests are raised.

Customer portal - Chatbot capability for Case status details Analyst and Manager portals - Review case details and route to appropriate Manager for approval and re-imbursement. Intelligent routing of claims to claim analyst by Identifying the correct claim type and routed to the appropriate claim analyst based on specialization (Dental, Maternity, Injuries) and work load.

Real-time Reporting of processed claim requests; prior duplicate requests raised, prior rejection reasons of previous claim made available to claim manager.

Automated validation and submission of the correct documents using Pega’s E-Form wizard

Integrating Pega CDH in the Claims application to up-sell more suitable plans.

Enabled score card models to show plan pricing details during up-sell campaigns.

Challenges we ran into

We have enabled Pega Text Analyzer from Pega Prediction as part of our Live News feed functionality. Please refer to our G drive link for more detailed explanation. We ran into a few challenges in understanding the capability and enabling the right functionality to extract the relevant keywords from the Live News API

Accomplishments that we're proud of

Live news feed integration and extracting relevant news articles using text analyzer Docu-Sign integration for enabling digital signature which helps in eliminating manual intervention and validate Claim details with the Claimant. Pega E-Forms capability to verify the uploaded bill details match with Claim details entered by the patient Pega CDH integration for an end to end capability to further up-sell other insurance products based on their existing medical conditions

What we learned

Got to brainstorm as a team to research on new Pega v8.7 capabilities and discovered the Pega Docu-Sign in-built shape for the same while exploring in-built integration capabilities. Also explored on Pega E-Forms which is an excellent value add.

What's next for Incedo_Insuranceplatform

Reach out to prospective companies requiring to implement a AI driven claims processing application Integrated Medical codes required for validation of Medical procedures Incorporate Auto-Adjudication processes

Built With

https://drive.google.com/drive/folders/1c90wbikamfmt5gv7557wkpaiumqy5wn-?usp=sharing

Submitted to

Pega Community Hackathon 2022

Created by

Hello everyone, as a PEGA certified senior system architect and decisioning consultant, I have provided my technical support in developing both Claims application (PRPC application) and Claims Insurance application (CDH application).

Sivaabinay C
Hello, Sivaabinay is a Pega certified senior system architect and decisioning consultant working at Incedo technology solutions Ltd.
Hi, Hemanth is a Pega Certified Architect at Incedo Technology Solutions ltd have contributed to implementing of Claims Insurance Application Development!

Hemanth Kumar
Hi, Its been a good experience and had implemented lot of functionalities technically as a part of application development
Sathish is a Pega Certified Architect at Incedo Technology Solutions ltd have contributed to implementing of Medi-Claim Processing Application.

sathish kumar
As a Pega LBA, I had worked with the team to ideate the various capabilities and identify the relevant use cases that we could include as part of our application

Priyanka Narayanan
As a Pega LBA, I helped team to build the application from scratch by creating the work flow and UI mock up's. Also i guided team on the functional clarifications to complete use case on time

swathi Molakalapalli
krishna koyyana
As a PEGA Developer , I Worked On Claims application Development and end to end use case.
Maheswari Vadapalli
Ranjith kumar
Surya chandra Neerati

Updates

Priyanka Narayanan started this project — Oct 07, 2022 01:50 PM EDT

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Priyanka Narayanan posted an update — Oct 07, 2022 12:05 PM EDT

Automated claim resolution process Why a Medi-Claim Application? Since 2020, the Indian insurance industry was worth a whopping $1.28 trillion. The Indian insurance industry is one of the largest markets in the world. The massive amount of premiums means there is an astronomical amount of data involved. Without artificial intelligence technology like machine learning, insurance companies will have a near-impossible time processing all that data, which will create greater opportunities for insurance fraud to happen. Why Medi-Claims are denied? Information about the patient is incorrect. The name could be spelled wrong, birthdate does not match, invalid or missing subscriber number, invalid or missing group number, etc. False or Duplicate medical claims Non-coverage of services. Invalid or missing documents to support the claims. Claims that are recorded as being related to a maternity related or cardiology.

Solution Overview: Straight through processing of claim requests in case of no previous duplicate claims or suspicious news items related to claim raised Customer portal - Chatbot capability for Case status details Intelligent routing of claims to claim analyst by Identifying the correct claim type and routed to the appropriate claim analyst based on specialization (Dental, Maternity, Injuries) and work load.

Real-time Reporting of processed claim requests; prior duplicate requests raised, prior rejection reasons of previous claim made available to claim manager. Automated validation and submission of the correct documents using Pega’s E-Form wizard Integrating Pega CDH in the Claims application to up-sell more suitable plans. Enabled sore-card models to show plan pricing details during up-sell campaigns.

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