Oracle Debuts Rules-Based, Configurable Health Insurance Claims System

Oracle has introduced Oracle Insurance Claims Adjudication for Health, which the vendor describes as a highly configurable, rules-driven claims system that helps health insurers to reduce administrative costs and increase member and provider satisfaction.

Among the advantages the new claims system affords to users, according to Oracle, are the ability to:

- Easily configure business rules to process more complex claim scenarios automatically, increasing consistency in claims payments while reducing the number of claims processed manually;

- Achieve more accurate first-pass adjudication of claims, reducing the number of claims requiring manual review and thus lowering administrative costs;

- Create business rules to precisely reflect the benefits offered, avoiding manual errors that can lead to over- or under-payment of claims;

- Accelerate payments to providers and members, improving service levels;

- Avoid payment adjustments by automatically detecting and flagging potential errors across all claim types.

"Health insurers are targeting their claims operations with the goal of reducing costs and increasing agility related to benefits, networks and re-imbursement models. However, they are often constrained by inflexible legacy systems that are expensive to adapt," comments Michiel Walsteijn, vice president, Oracle Health Insurance Solutions. "Oracle Insurance Claims Adjudication for Health offers a flexible, highly scalable component approach which enables a phased implementation path. The rules-based solution offers a higher level of automated claims adjudications, improves quality and transparency, and provides the flexibility that insurers need to outpace the competition."

The vendor asserts that configurability of Oracle Insurance Claims Adjudication for Health enables payers to quickly adapt to support new products and benefits, or to meet changing regulatory demands. For example, insurers can create rules governing any type or set of codes, including procedure, diagnosis, provider, facility and custom codes. The solution is International Classification of Diseases, 10th Edition (ICD-10) compliant, preparing U.S. health insurers for the 2013 phase-in date, Oracle says.

The solution supports major medical, dental, vision and behavioral health claims, according to Oracle, and it is designed to scale for very high volumes to support consolidation of various claims engines into a single instance. Oracle Insurance Claims Adjudication for Health also integrates easily with financial systems for end-to-end claims processing and payment, the vendor says. Additional out-of-the-box integration points support the exchange of data with customer relationship management (CRM), membership accounting, provider management and other critical payer systems, as well as with third-party systems, according to Oracle.

Anthony O'Donnell has covered technology in the insurance industry since 2000, when he joined the editorial staff of Insurance & Technology. As an editor and reporter for I&T and the InformationWeek Financial Services of TechWeb he has written on all areas of information ... View Full Bio