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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