Electronic Smart Approvals

11-04-2012 |

Fast, accurate and technology assisted approvals are the key to a successful TPA or insurance companies.

Allowing the company to:

  • Correctly evaluate the beneficiary health needs.
  • Regulate the loss ratio within acceptable boundaries
  • Substantially reduce insurance abuse
  • Significantly increase the approvals processing capacity and reduce its cost

As a result insuring the satisfaction of all the insurance contract parties!


Approvals Engine


Online Approvals

  • Web enabled end to end approval processing
  • Rule based and highly customizable automatic approvals

Automatic approval by the system can be granted once a set of customizable rules has been validated:

  • Policy benefit limits
  • Policy level rules
  • Claim level rules
  • Service level rules
  • Insured level rules
  • Insured medical history
  • Insured state
  • Provider level rules

System Assisted approvals:

In case an automatic approval has been denied, the request is handled by a system assisted approval process.


The system assists the user by:

  • Highlighting the reasons why the automatic approval was not granted
  • Displaying the insured medical history and laying emphasis on important factors:
  • Medical cases timeline
  • Claims distribution
  • Service Distribution
  • Relevant Charts
  • Analyzing requested services recurrence and highlighting potential abuse information
  • Routine approvals assessment and review

The system allows the manager in charge to routinely evaluate the quantity and quality of the approval’s department performance

  • Review granted and denied approvals
  • Review the beneficiary medical history.

Offline Approvals

In case of internet shut down, power cuts in covered areas our system still allows the service providers to serve the beneficiaries by introducing the concept of offline approvals.
The service provider will use a light desktop application to stores his claims locally and at the same time be granted an approval number over the phone.
Once the situation returns to normal the service provider will upload his claims instantly.

Advantages:

  • Correct approval decision in less than 1 minute!
  • High approval processing capacity
  • Abuse reduction
  • Well established communication grounds between all insurance contract parties
  • Seamless approval status tracking
  • Up to date Info (TPA)
  • Loss Ratio
  • Claims Statistics
  • Approval Statistics
  • Medical History
  • Approval History