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Jarus Automated claims adjudication is an IBM SOA Connect certified product that
eliminates process latency by automating routine decisions that claims adjusters
make every day. Using this system Insurers are able to improve claim efficiency,
reduce claim leakage, increase customer satisfaction and implement rule changes rapidly.
Challenges
- In spite of many technological advances, claim adjudication is still a manual process requiring many human touch points.
- Without automation claims adjusters workload remains high resulting in unnecessary delays and high operational cost.
- Business rules are buried in program logic. This increases time and cost for insurers to make changes to the claims adjudication rules.
Solution
Jarus Automated claims adjudication fulfills the end-to-end claims adjudication process by automating key claims decisions.
The system makes these decisions efficiently and in a manner consistent with claims adjusters using the knowledge supplied
to it in the form of business rules. It complements the work of claims adjusters by automating routine transactions while
leaving the complex and unique situations to the experts. The business rules are in a human readable format allowing business
analysts and SME to readily customize and extend the business rules to suit an Insurer’s needs.
Technology
Jarus Automated claims adjudication is based on state-of-the-art Business Rule Management Systems (BRMS) technology. The system is made up of 5 key components.
- Claims Service Adapter, a component interface that is invoked by an Insurer’s claims backend systems when a claims decision needs to be made.
- Rule Repository, a central database of claims adjudication and compliance rules.
- Business Rule Engine, that executes the rules to reach an underwriting decision.
- Rule Management Application, a web-based application used by Business analysts and SME to view and modify business rules.
- Rule Regression Testing Framework to test and validate rule changes.
Claims Service Adapter
The adapter simplifies integration of the Automated Underwriting system with Insurer’s claims backend systems.
Based on Web services and ACORD XML standards, it plugs easily into an existing Enterprise Service Bus (ESB) to
enable enterprise-wide access to the Claims service in a service oriented architecture.
Business Rule Engine
A commercially off-the-shelf business rule engine that executes the rules. We currently support Fair Isaac Blaze
Advisor and Yasu QuickRules.
Rule Repository
A central database of claims adjudication and compliance rules. Rule repository is typically maintained in a
relational database. We currently support IBM DB2 and Oracle.
Rule Management Application (RMA)
A web-based application that is targeted at business analysts and SME, making it easier for them to view and modify
business rules. RMA uses "rule templates" to present the rules in an English-like format that can be edited by
non-technical users without introducing errors. The product includes a collection of generic rule templates that covers
most insurance claims rules. These templates can be further extended if needed.
Rule Regression Testing Framework
One of the most time consuming activities in any project is testing. Rule regression testing framework simplifies and
automates rule testing. Using test data supplied in a formatted Microsoft Excel spreadsheet, the framework is able to
simulate tests, execute them, compare actual outcome with anticipated outcome and report discrepancies. Detailed
information on the results of the regression test is presented to enable Business analysts to identify, analyze and
resolve discrepancies found during testing. The tests can be run and re-run many times whenever a rule changes to validate
the changes.
Business Benifits
- Improves claims processing speed.
- Reduces workload for claims adjusters.
- Reduces errors and claim leakage.
- Capability to flag suspected fraudulent activity.
- Ability to adapt faster to satisfy business needs.
Benefits to IT
- Jarus Automated claims adjudication is SOA Ready. It offers a good, clean architecture.
- It integrates easily with existing claims backend systems.
- Rules are externalized, centralized and kept as rules in a rule repository. This provides a clean separation
between business rules and data/user interface logic.
- Rules can be reused across systems and business units.
- It encourages use of an enterprise-wide, common Business Object Model.
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