*Winners of NDHM Healthathon 2020

ClaimGenie

AI Assisted Insurance Claim Processing

For Patients

Hospitalisation is a stressful event
Unnecessary time spent by the patient’s family in arranging for paperwork for Insurance could be better spent with the patient

Lack of transparency throughout Claims lifecycle
Customers want to be kept informed throughout every stage of claims lifecycle

For Insurance Providers

Heavy Claims Processing Costs
Cost of Claims Processing stands at a 10-12% of total Operating Expenses

Fragmented TATs dilutes Customer Experience
The TAT is not standardised even within the same Insurer, due to multiple claim processing entities(TPA)


pre-auth

Pre-Auth Experience (Before Treatment) is fragmented even
within the same provider depending on which TPA you are using.
*(IRDAI enforces an SLA of 6 hr pre-auth process)

discharge

Post-Discharge (After Treatment) experience become even more fragmented (varying from 95% to 60% claims being processed in <1hr) depending on which TPA you are using

How do we solve It?

National Health Stack(NHS) is trying to push for digitization of health documents. Which opens up the possibility to revolutionize the claim processing.
Getting rid of the physical documents collection & manual claim processing method and replacing it with automated rule engine can help us reduce the time required to process claims by order of magnitude.

Personal Health Records

ClaimGenie collects the health records from the PHR database being created as part of the National HealthSatck

E-Claims

E-Claim *(based on 15C) that allows Providers to send us patient’s data in standardized format over an API

Policy Markup Language

Policy Markup Language, that allows us to convert any Policy to a set of machine readable rules/conditions

Rules Engine

Rules engine that allows us to compare b/w patient’s medical records to what’s allowed in her policy

claim_flow

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