.svg){kind=logo}
Claims management for a large health insurer in Mexico
Read case study
Claims management
AI-driven claims management platform for health & life insurance to automate claims processes, reduce leakage and improve loss ratios.
3-7x
Return on investment within first 12 months of implementation
75%
Straight through processing achieved, with 99% accuracy.
Features
Go beyond straight through processing
Qantev streamlines your end to end claims management processes and gives you key decision-making insights along the journey.
Data extraction & OCR
Specialized OCR dedicated to insurance supporting documents, printed and handwritten, latin and non-latin characters.
Document classification
Supporting document identification and classification, template and language agnostic.
Member & provider identification
Member identification & membership check, coupled with accurate recognition of healthcare providers.
Required document check
Automated missing document check customized to specific process.
Medical coding inference
Automated medical coding inference, code agnostic (ICD 9, ICD 10, CPT, etc).
Data enrichment
Provider enrichment, readmission flagging, episode grouping, cost normalization, geocoding, referral patterns mapping.
Data cleaning
Cleaning rules, discrepencies correction, fixing of structural errors and unwanted outliers, missing data.
Data governance
Data lineage, usage logging, operations history.
Coverage check
Automated checks against member's policy coverage, rules and exceptions.
Medical necessity check
Relevance check of medical care, vs member's medical situation and journey.
Provider contract check
Submitted claims consistency checks vs price lists and negotiated clauses.
Exception & limits automation
Complex reimbursement rules and exceptions supported by Qantev algorithms.
Reimbursement calculation
Automated reimbursement amount computation, taking into account specific rules.
Claims & payment history
Detailed view of member's status, claims and payment historical data.
Collaborative adjudication
Claims handlers and teams can collaborate on complex cases.
Activity tracking
Automatic log and tracking of all activities related to all cases.
Benefits manager
Define and update complex benefit rules into your products.
Exclusions manager
Define and update complex exclusion rules into your products.
Limits manager
Define and update limits (amount, quantity, period & more).
Policy usage tracking
Summary of policy usage and remaining available reimbursement amounts.
Normal & customary rules
Define and update base reimbursement approach that applies for all products.
Policy holder details
Member details, including medical history, policy rules, and beneficiary information.
Contract & policy viewer
Quickly find a specific policy or contract with filters for precise and efficient retrieval.
Automatic authorization calculations
- Policy limits and business rules calculation to produce authorized amounts.
- Provider contracts and regulated fees leveraged to calculate costs.
- Historical market data used to estimate prices.
Integrated workflows
- Fully automated data acquisition and adjudication for automated approval.
- Optimized interfaces for real-time request handling in call centers.
- Complete integration with direct billing for straight through payment processing.
Correspondence generation
- Creation of letters of authorization, denial with explanation.
- Automated letter generation from the case data, based on configurable templates.
Request history
- Member and provider historical data leveraged to improve responses.
- Automated medical consistency and intelligence checks to support decisions.
Claims registration
Health care providers can submit claims and multiple medical documents directly through a web portal.
Eligibility & benefits check
Health care providers can quickly check eligibility and benefits for every insurance member.
Prior authorization check tool
Define and update complex exclusion rules into your products.
Notification center
Real-time notifications on incomplete cases and claim statuses.
Claims status & history
Health care providers can check the status of their submitted claims.
Prior authorization requests
Health care providers can submit prior authorization requests.
How it works
Empower your claims handlers with specialized AI
Smarter data extraction
OCR & AI to capture, clean, enrich, understand and digitise data automatically from any claims documents received, to reduce manual input.
Smarter coding & flows
AI to automatically infer medical codes, and deliver automatic triage of the claims, making flows and processes more efficient.
Smarter checks
AI to assess the medical consistency & validity of patient's journey or diagnosis against market practices, to detect anomalies.
Smarter calculations
AI to understand complex policy coverages and calculate the right reimbursement amounts, reducing TAT and human errors.
Smarter predictions
Integration with third party databases and feedback loops to improve platform accuracy & intelligence.
Get 3-7x ROI in 12 months
Leakage reduction
Automation, insights & FWA detection to improve loss ratios and profitability.
Rapid deployment
4-6 months average deployment for quick business wins.
Faster claims TAT
Straight through processing to Improve your customer experience and NPS.
Easy integrations
Modular and API-driven architecture to fit within your complex ecosystem.
Specialized AI
900M medical claims processes for highest accuracy and domain knowledge.
User friendly
Shorten learning processes when onboarding new claims handlers.