Cryptographic Claims Module for Secure ICD-10 Adjudication
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Solution Overview
Problem
Conventional supplemental health insurance methods are inadequate in addressing modern financial burdens, leading to low utilization rates and misalignment with employee needs, and lack secure and efficient claim processing systems.
Innovation Solution
An intelligent insurance design system that includes automated administration, secure document transfer, and claim submission, enabling personalized plan management, automated underwriting, and AI-assisted claim adjudication through a claims module that uses ICD-10 codes for rapid and secure claim processing.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Adaptability or versatility
If conventional supplemental health insurance methods are used, then basic coverage is provided, but utilization rates are low and employee needs are not met
Solution Approach 1:
The system performs preliminary actions by automatically generating personalized plan recommendations for employees before they need to make decisions. The AI analysis of medical records and financial data pre-prepares customized coverage options, eliminating the need for employees to navigate complex plan selections manually and increasing utilization through proactive, personalized engagement.
Solution Approach 2:
The system enables self-service through automated claim submission and adjudication. Employees can submit claims through the platform, and the AI system automatically processes and adjudicates claims using ICD-10 codes and benefit plan rules, reducing administrative burden and improving access to benefits without requiring manual intervention.
2Reliability
If conventional claim processing methods are used, then claims are processed, but network and computer resources are burdened and security is insufficient
Solution Approach 1:
The system replaces manual and conventional automated claim processing mechanics with AI-based adjudication. The AI system uses machine learning models to analyze medical records, ICD-10 codes, and benefit plan rules, automatically making coverage determinations without requiring extensive human review or complex network infrastructure for manual processing.
Solution Approach 2:
The system changes the processing parameters by implementing automated adjudication based on ICD-10 code recognition and structured benefit plan rules. This transforms claim processing from a resource-intensive manual review process to an efficient automated system that processes claims based on predefined parameters and algorithms, reducing network burden while improving security through consistent, rule-based decision-making.
3Adaptability or versatility
If conventional insurance design and pricing methods are used, then standard products are offered, but product/market fit is poor
Solution Approach 1:
The system performs preliminary underwriting and plan design actions using AI analysis of employee medical records and financial data before products are offered. This preliminary intelligence gathering enables customized plan design that fits specific market segments, improving product/market fit by aligning coverage with actual employee needs and risk profiles.
Solution Approach 2:
The system implements dynamic pricing and plan design that adapts to individual employee profiles. Rather than offering static standard products, the AI system dynamically generates personalized recommendations based on real-time analysis of medical utilization patterns, financial responsibility data, and benefit plan parameters, allowing the product offering to evolve with changing market needs.
Data Source
AI summary
The disclosure is directed to systems and methods for the transfer of documentation over secure networks. In some embodiments, the system includes cryptography that enables network security while displaying graphical user interfaces and receiving inputs into the system. In some embodiments, the inputs include one or more forms which the system is configured to determine codes. In some embodiments, the inputs include information pertaining to confidential data. In some embodiments, the system includes modules that enable users to enroll in programs and receive payments over secure networks relating to the programs.