Health Insurance Claims and PreAuthorisation management is a complex process. We have spent over hundred man years to perfect our solution for your needs.
JSure platform is a custom enterprise solution which works as a part of your core insurance system.
Web based claims file entry
Payments Management for Providers
Document Exchange with Health ProvidersIntegrations
Doctor, Speciality and Title Catalog
Core Insurance Platforms
Pricing Integration with JMed
Policy Rules Integration with JRules
Integration with UW Exemptions
Intgegration with Hospital Information Systems
Integration with Pharmacies Through JPharmacy
Policy Rules Management
Each policy is different so is JRules. We know you have hundreds of different enterprise customers and each is changing original policy templates.
JRules has three contract layers
Insurance Provider Policy of Conduct
Insurance Policy Base Rules for Each Health Product
Additional Policy Rules Accustomed to your Enterprise Customers Needs
We have screened over hundred thousand pages of insurance policies and created over 2000 business rules to match your needs.
The platform is full customisable by your policy managers and products owners thanks to Decision Center. JRules is a unique design implemented on IBM Operational Decision Manager the leading rules solution with %30 market share.
JRules is fully integrated with JPolicy Manager for ease of Group Policy creation. Each Group policy has it's own collection of rules.
Scope of Rules
Covered and Uncovered Diseases Groups for inpatient, outpatient and treatment
Network Management Rules
Policy Management Rules
Pricing/Service Procurement Rules
Deductables and Cover Limit Rules
Pharmacy and Vaccination Rules
Waiting Period Management
Emergency Admission Rules
Maternity and New Born Rules
Over 250 parameters are checked and controlled
ICD-10 Codes, Health Service Codes,
Age , Gender,
Cover Limits and Cover Redirection
JPolicy Rules Manager
Good Job! You have the new enterprise group deal and signed the contract ! Now you need to onboard your insured and define special rules that your new enterprise customer has asked from you to sign deal. Thanks to JRules you have a catalog having thousands of rules to match up with the contract items.
We all know it's hard to implement new rules and it quickly becomes another IT project which takes months to implement while your pre-authorisation/claims team struggle to manually run the operations.
Thanks to JRules you are able to implement new rules in hours instead of months. Once the necessary rules are in place it's time to call the policy production team.
Policy production is a key area where small mistakes take out millions from your budget. It's very important to chose the right rules which comply with the contract. Yes it's a 50 page contract which generally has two hundred business rules but which to choose from is a dilemma for the ordinary.
So we made it easy for any employee to choose from a simplified selection process step by step.
First you choose which illnesses are covered, than you choose waiting periods, limits, cover redirections, pregnancy and maternity emergency admission rules and whoala! you have made it the first time and correctly thanks to JPolicy Managers intuitive easy to use interface.
JMed Master Data
Now you have the system and technology but what about medical master data. Our team of Medical Doctors specialised in insurance has worked for years to perfect our catalog for a system with minimum leakage available on the market.
Scope of JMed
Full Health Services Codes for TTB and HUV
Full Service Codes of 12 Health Providers which holds %50 of market (200'000+ Code Mappings)
Mapping of all Government Catalogs and Health Service Provider Catalogs into HUV++ (14500 Code Mappings)
Medical Doctor Speciality Catalog (100+ Medical Speciality and Groupings)
ICD-10 Extended Catalog (18000+ ICD-10 codes)
Illness Groupings (800 Illness Groups matched with service codes, ICD-10 codes,Service + ICD*10 codes, Doctor Speciality Branch )
UW Exemption Codes (1250+ Codes with ICd10, Service Code) Mappings
Integration with Health Providers is a rigorous task, JSure B2B is a tested environment for the enterprises.
One standardized approach for the network means simpler, faster integration. Our teams are ready to onboard your biggest health providers in days instead of months.
Scope Of Integration Services:
Policy Validity Check
Submit a Claim File
Get Status of Pending Claims Files
Report Claims For Payment
Health Service Codes Master Data
Policy Validity Check
JPACS for Medical Image Transfer
In order to authorize medical procedures many times insurance medical doctors request radiology results and images for eligibility. These documents sometimes takes days to transfer and review.
With JPACS in minutes your medical reviewers cas access to all medical images and lab results whether from a desktop or the comfort of a mobile phone.
JPACS uses international PACs standart to communicate with medical imaging devices and lab testing equipment. Philips Healthcare, GE Medical, Siemens Healthcare and many other global brands provide support for PACS standart.
It's best that you take your medication and go to rest ! Wait a minute can authorisation of an prescription with an insurance company take as long as thirty minutes? Sometimes it does.
With JPharmacy your customers can get online authorisations within seconds while you control dosage, gender, vaccination rights, doctor speciality, equivalent medication, pricing and many other aspects described in your health insurance policy.
UW Exemptions and disease related medication exclusion are also part of the solution which can stop medicinal leakage.
Permanent medication plans are also managed for ease of use and customer satisfaction.
Pharmacies can run the settlement processes with the Insurance Provider. Payment requests, delivery of prescriptions and all necessary collateral documents can easily be achieved with a click of a button.
Medicine change, new drugs are introduced into market while other are removed. Prices and dosage change. JForce medical team makes sure you are up to date with each new medication, prices and content.
Fraud / Abuse Management / Analytics & Reporting
JBig Anomaly Detection
The first stage of fraud and abuse management is Anomaly Detection, because there are no ready data sets to leverage Machine Learning algorithms.
JBig Anomaly targets not only fraudulent activities but also ways to explore areas to help you with immediate financial gain, get more insight into product performance, increase your bargaining power with providers. Manage your claims teams and pre authorisation rules better by increasing automation levels even higher.
JRadar for Healthcare
Instant rejection of demands related to Irrelevant Disease Codes
JBig for Analytics
With JBig's ready built assets for the health insurance data analytics your reports are more accurate. We provide ROLAP data models and consulting services to implement your health datamarts for future use by reports, predictive and prescriptive analytics, abuse waste and fraud management.
JRenewal for Risk Management
Protect your Life-Long High Value Customers and Leave Low Potential Customers Behind.
IBM Decision Automation and Analytics will help you to grow your portfolio in a profitable way.
First, we assess your renewal rules. Review your documents and apply them in to world’s #1 decision platform. Ease of Management in IBM Decision Center enables business users to simulate, change, test and activate new versions easily.
Our analysis team analyze Customer scores such as Life-long Value, Policy Profit/Loss Ratio, General Loss Rate, Customer Segment, Price Precision, Churn Score in the Second phase. This helps to close your gaps by applying advanced analytics. Our solutions may be implemented by using SPSS, Watson AI, Knime or R and Python in Anaconda.
In third phase as part of your business rules we apply our real-time analytics engine which you can score advanced renewal risks in shorter than one second. Risk scores can be used not only for micro segment but also as authorizing flag calculated for your private customers or a drop or change of a price in policy demands.
Underwriting Management and Policy Production
JDocs for Insurance and Policy Creation
JDocs for Health Insurance and Policy Creation
Paper forms, medical examinations and initial health insurance onboarding process requiring data entry for Insuring and Policy creation are simplified with JDocs.
Your applicants may fill the Smart Health Claim forms for entire family members via their smart phones. Smart forms have most valuable questions for time saving and optimize defined risk group questions.
Paper forms can also be imported with Smart Scan for detailed review by insurance brokers.
Undertaking process is simplified for collecting machine-based risk analysis, medical examination, external medical record research and sensitive data of other insurance companies.
Tracking service levels for onboarding will provide easily define and improve critical optimization points for best Customer experience.
Insurance Rules Management for Healthcare Services
Insurance Automation Rules for Health Insurance provides with up to %90 direct processing for your teams.
Whether you are using digital tools or traditional forms, we catch important critical disease indicators and decide whether you need to apply an exemption or extra contribution.
Your medical insurance expert may easily evaluate only the files needing attention with this information.
Better Customer Service
JSure Mobile PreAuthorisation
JSure Mobile Pre-Approval
JInform for Health Insurance
Inform your patients while waiting for pre-approval.