Our claims management engine is at the core of the solution. The engine is based on Netcetera’s decade-long experience in processing healthcare claims for regulators and insurance companies. In partnership with Greenrain, we maintain and guarantee continuous compliance of the system with local regulations.

Features:

• End-to-end integration with regulators or care providers
• High throughput designed for large volumes of claims
• Adaptable for various standards and custom rules
• API interface for full insurance system integration and no-code customization

Netcetera’s own ML-based models detect waste, abuse, and fraud in healthcare claims. The system can identify deviation in behavior, in addition to adjudication and medical necessity rules. This module contributes a significant amount of trust in the decision-making process of the system because it prevents stakeholder behavior that is against the established norms.

• State of the art Machine Learning models designed for healthcare claims
• Risk scoring of individual claims, line items, and clinicians
• Self-adaptive system that learns with each claim decision

The system is operated in-country on Azure and fully managed by Netcetera. You use the benefits without operational costs, with an appropriate commercial usage-based pricing model.