Claims Adjudication processes can be very complex and using a business rules engine to automate the claims process can save significant time, reduce errors and increase customer satisfaction. North52’s Decision Suite helps you implement complex rules on the Microsoft Dynamics 365 Platform.
In this series of articles, we show how an automated claims process for dental insurance can be implemented using the North52 Decision Suite, Dynamics 365 and Power App Portals. Review the articles for a deep understanding of how the business rules logic is implemented using Decision Tables.
Rules for Claims Adjudication
There are a significant number of rules and checks that need to be processed as part of the automated claims adjudication process using the North52 Decision Suite. This series of articles will cover the rules relating to a specific policy that a customer is claiming against. These rules include:
- Treatment coverage, including percentage coverage and the maximum amount of coverage for specific treatments
- Previous claims restrictions
- Policy restrictions for waiting periods
- Policy restrictions for treatment-specific maximum benefit
- Policy restrictions for overall maximum benefit
- Once the individual claim item has been assessed, the claim item is updated with the outcomes and then additional rules are applied to update the claim (header) record
Additionally, we show how you can automatically test the business rules using North52 TestShield for a specific scenario: