Claims management system and software for insurance

Digitising the provider-to-payer relationship

In an increasingly digital world, removing the need to submit paper bills to health insurers offers medical providers and their patients a fantastic opportunity for improvement. The savings for insurers can be dramatic: manual claims submissions in the US are estimated to cost 74 cents, electronic submissions just 26 cents – a 63% improvement.

Digitisation offers further benefits:

Better management of fraudulent claims
Faster intervention by the insurer
Increased purchasing power for the insurer
A greater customer experience

1-2% reduction in claims experience
represents a 10-20% improvement in productivity

Over 20 successful implementations

Millions of claims paid every year
with Actisure for over 10 years

Actisure Claims to reduce costs and increase productivity

Every year, for over ten years, Actisure Claims, a core module of our platform, has successfully adjudicated and paid millions of claims, ranging from 1 Renminbi for an aspirin through to complex in-patient cases costing hundreds of thousands of dollars. Our clients routinely deal with thousands of medical providers; they must manage these relationships by delivering consistently high levels of service.

Actisure Claims, our claims management system, is probably the most sophisticated adjudication engine available. Leveraging advanced Microsoft Windows Server technologies such as MSMQ messaging and a scalable, open services architecture, and thanks to one of the largest development teams in the medical insurance industry, we are able to offer a completely unattended automatic adjudication of medical claims anywhere in the world.

Actisure Claims reduce costs and increase productivity

Managing the complexity of claims

Actisure’s comprehensive set of open services support all the stakeholders in the healthcare insurance value chain:

Doctors
Hospitals
Brokers
Insureds
HR departments
Our clients

Furthermore, the services can interact with other applications in your business to deliver even greater value. From the moment a patient first engages with a provider to establishing eligibility and treatment pre-authorisation, all the way through to the claim being paid, Actisure can help.

The Actisure services are used by our own web portals for providers, customers and HR departments. Leveraging responsive design techniques, our clients are able to quickly deliver solutions to exploit the opportunities that a Digital Health platform such as Actisure provides.

Our provider portal enables an eligibility request
to be made to Actisure in real time.

It will display member details, benefits information
and a photograph.

Actisure offers a single-screen view of each beneficiary’s complete utilisation, whether claims are in progress or have already been paid.

This includes a real-time calculation of the amount of benefit remaining per detailed limit, instantly answering that key question: “Am I covered for this?”

A single screen view of each beneficiary’s utilisation

Actisure seamlessly handles multiple sources. Managing up to 5 million electronic claims per year per single message queue, it is designed to support your business from end to end, whether you are deploying manual or digital processes.

Addressing the challenge of the adoption of electronic medical trading networks, Actisure Claims allows insurers to define multiple standards within a single instance.

This provides the transformation and mapping services to take a digital feed, interpret the medical procedure and link that to the insured’s entitlements.

Actisure’s extensible and flexible framework
can record whatever data is required.

Actisure’s payment processes provide for the automatic recognition of provider terms, application of discounts for prompt payment and amalgamation to the lowest cost routing for settlement.

Key benefits of our claims management system

Cost reduction

Earlier intervention
Fraud management initiatives
Tariff management greatly reduce claims costs

Sustainable relationship between Payers
and Providers

Actisure offers services for all the stakeholders in the medical insurance value chain: doctors, hospitals, brokers, insureds, HR departments and insurers.

Improved fraud management

Actisure’s rules engines automates many adjudication processes that have historically been undertaken manually. This allows experienced claims assessors to concentrate on the ‘softer’ side of reviewing claims.

Concentrate effort
on high value claims

Actisure enables a variety of claim adjudication processes, starting from STP processing on low-value claims to case management capabilities on the most complex cases.

Discover the other modules

Product management Policy administration

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