Cortex Claims Transformation

Improving Healthcare claims processes for payers and providers with AI-powered insights.

Cortex Claims Transformation Improve Accuracy

Cortex Claims Transformation Helps Improve Customer Experience and Increase Process Efficiency

Insurers are challenged to manage claims, remittance, and payment data across the claims adjudication and policy management systems. Insurers are looking to AI for improvements in a number of areas: improved adjudication accuracy, automation rates, and speed; and, movement towards real-time auto-adjudication, and “touchless” next-gen customer experience.  Cortex Claims Transformation solutions help insurers achieve these objectives.

Intelligent claims models

CognitiveScale has deployed AI solutions in areas like Exceptions and Adjustments Management, Denials Management, and Auto Adjudication.  These solutions help in areas like identifying duplicates and scoring rejects, and in helping to automate corrections. We have also deployed Machine Learning (ML) solutions for document intake, interpretation, and insights in support of claims processes.

Claim Insights based on temporal, multidimensional profiles

CognitiveScale’s Profile of One is a 360-degree, temporal, longitudinal view of key entities (Insureds, Claims, Agents, Products). Profiles form a foundation for personalized insights and proactive interventions, so in the case of a claim profile, CognitiveScale can enable advanced analysis of claims against prior claim history (temporal analysis), all of an insured’s other claims, various models (edits and validations, fraud detection), or against rules engines (pricing algorithms).

A low-code, assembly line of Cortex Claims Transformation solutions

CognitiveScale’s Cortex software enables clients to manage an assembly line for the development, deployment, management, and optimization of numerous AI-powered solutions. In order to implement and scale claims-related use cases, models need to leverage multiple data sources. Models themselves are likely focused on specific information about the claims process, so there is the need to combine models, algorithms, and rule sets – and there are likely many of these that need to be deployed. Consequently, our clients are interested in an AI platform and toolset that can enable a level of model combination and orchestration that surpasses what adjudication engines or transaction processing services can do.

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