NewgenONE Platform for
Enhance Claims Management, from Instant Verification to Tailored Updates
Reimagining claims processing with AI-driven triage, centralized document management, and enhanced straight-through processing—delivering faster, more accurate payouts for an improved customer experience.
Automating health insurance claims journey can help process large volumes of transactions while improving claims settlement accuracy and minimizing medical claims errors. Newgen’s health claims automation solution offers comprehensive features to enhance the quality of services to policyholders while improving the overall health claims management process, making it faster, more accurate, and efficient.
“With Newgen, we achieved 60% faster claims processing through AI-powered automation and an 85% reduction in claims leakage with robust fraud detection, driving compliance, financial savings, and improved customer satisfaction.”
Director of Claims, Major Health Insurance Provider
Learn what Newgen’s Digital Claims Automation Solution can do for you
Automated Claim Eligibility Validation
Conduct instant, automated verification of claim details by cross-referencing with policy data, network hospitals, and treatment details. Reduce errors and prevent unnecessary claim denials while speeding up verification.
AI-driven Claims Triage
Leverage AI to analyze claim data, categorize claims by complexity, and route them accordingly. Identify potential fraud, prioritize high-risk cases, and ensure only relevant claims reach manual review.
Auto-adjudication Engine
Automate claims adjudication by configuring custom rules to assess low-risk claims for instant approvals. Enhance process accuracy by employing AI models to assess compliance and ensure policy alignment.
Unified Claims Workbench
Get a centralized platform that consolidates all claims activities, from claim receipt to settlement. Empower claim adjudicators to review, analyze, and manage cases effectively using a single interface.
Automated Claim Eligibility Validation
Conduct instant, automated verification of claim details by cross-referencing with policy data, network hospitals, and treatment details. Reduce errors and prevent unnecessary claim denials while speeding up verification.
AI-driven Claims Triage
Leverage AI to analyze claim data, categorize claims by complexity, and route them accordingly. Identify potential fraud, prioritize high-risk cases, and ensure only relevant claims reach manual review.
Auto-adjudication Engine
Automate claims adjudication by configuring custom rules to assess low-risk claims for instant approvals. Enhance process accuracy by employing AI models to assess compliance and ensure policy alignment.
Unified Claims Workbench
Get a centralized platform that consolidates all claims activities, from claim receipt to settlement. Empower claim adjudicators to review, analyze, and manage cases effectively using a single interface.
Features of Claims Processing Solution for Health Insurance
Omnichannel Claim Initiation
Efficiently capture claim details and policyholder information from multiple sources, including emails, portals, branches, and social networks. Fetch and categorize documents updated during claim initiation by the backend system for easy reference. Leverage inbuilt OCR extraction capabilities to retrieve relevant data from standard documents uploaded during the claims process. Effectively manage and streamline various pre-authorization requests, including new pre-authorization, pre-authorization extension, additional information requests, and pre-authorization cancellations.
Rule-based Claims Adjudication
Automate case routing to adjudicators based on multiple set criteria such as claim amount, claim type, approval authority, and case level complexity. Execute payable summary calculation with smart rule-based system. Automatically classify claims as ‘fast track’ or ‘non-fast track’ with predefined business rules. Enable case referral to various departments such as CSO, fraud, and investigation, underwriting, and provider enrolment without interrupting case processing.
Seamless Integration
Seamlessly integrate with policy admin system (PAS) to fetch all policy and coverage-related details in a single screen. In addition, integration with third-party systems can capture details and perform checks and validations.
Centralized Document Management
Benefit from a central document repository that allows easy access to stored documents. Quickly retrieve provider-related documents like rate lists, agreements, etc, while processing cashless claims.
Real-time Document Generation
Achieve real-time document generation, including claim acknowledgment letters, approval letters, and settlement letters. Auto-generate file payments for providers and enable claim payouts, including generation of pay advice and accounting entries.
Monitoring and Insights
Establish defined KPIs to track and assess user efficiency. Bring transparency and timely resolutions to claims processing with escalation matrix and monitoring reports. Users can get real-time status updates of claim registration, tracking, and management of submitted and generate comprehensive claim reports linked to customer utilization, network availability, and costs.
Omnichannel Claim Initiation
Efficiently capture claim details and policyholder information from multiple sources, including emails, portals, branches, and social networks. Fetch and categorize documents updated during claim initiation by the backend system for easy reference. Leverage inbuilt OCR extraction capabilities to retrieve relevant data from standard documents uploaded during the claims process. Effectively manage and streamline various pre-authorization requests, including new pre-authorization, pre-authorization extension, additional information requests, and pre-authorization cancellations.
Rule-based Claims Adjudication
Automate case routing to adjudicators based on multiple set criteria such as claim amount, claim type, approval authority, and case level complexity. Execute payable summary calculation with smart rule-based system. Automatically classify claims as ‘fast track’ or ‘non-fast track’ with predefined business rules. Enable case referral to various departments such as CSO, fraud, and investigation, underwriting, and provider enrolment without interrupting case processing.
Seamless Integration
Seamlessly integrate with policy admin system (PAS) to fetch all policy and coverage-related details in a single screen. In addition, integration with third-party systems can capture details and perform checks and validations.
Centralized Document Management
Benefit from a central document repository that allows easy access to stored documents. Quickly retrieve provider-related documents like rate lists, agreements, etc, while processing cashless claims.
Real-time Document Generation
Achieve real-time document generation, including claim acknowledgment letters, approval letters, and settlement letters. Auto-generate file payments for providers and enable claim payouts, including generation of pay advice and accounting entries.
Monitoring and Insights
Establish defined KPIs to track and assess user efficiency. Bring transparency and timely resolutions to claims processing with escalation matrix and monitoring reports. Users can get real-time status updates of claim registration, tracking, and management of submitted and generate comprehensive claim reports linked to customer utilization, network availability, and costs.
Learn what Newgen’s Digital Claims Automation Solution can do for you
Automated Claim Eligibility Validation
Conduct instant, automated verification of claim details by cross-referencing with policy data, network hospitals, and treatment details registered in the Council of Cooperative Health Insurance (CCHI) database. Reduce errors and prevent unnecessary claim denials while speeding up the verification process to meet local regulatory requirements.
AI-driven Claims Triage
Leverage AI to analyze claim data, categorize claims by complexity, and route them accordingly. Identify potential fraud, prioritize high-risk cases, and ensure only relevant claims reach manual review. Integrate with national data sources like Yakeen and Masdr for enhanced identity verification and accuracy in claims processing.
Auto-adjudication Engine
Automate claims adjudication by configuring custom rules to assess low-risk claims for instant approvals. Enhance process accuracy by employing AI models to assess compliance with local health insurance regulations and ensure alignment with policy terms approved by CCHI.
Unified Claims Workbench
Access a centralized platform consolidating all claims activities, from claim receipt to settlement. Empower claim adjudicators to review, analyze, and manage cases effectively using a single interface, with integrated support for payment processing through MADA, UR Pay, STC Pay, and SADAD for seamless claims settlements.
Automated Claim Eligibility Validation
Conduct instant, automated verification of claim details by cross-referencing with policy data, network hospitals, and treatment details registered in the Council of Cooperative Health Insurance (CCHI) database. Reduce errors and prevent unnecessary claim denials while speeding up the verification process to meet local regulatory requirements.
AI-driven Claims Triage
Leverage AI to analyze claim data, categorize claims by complexity, and route them accordingly. Identify potential fraud, prioritize high-risk cases, and ensure only relevant claims reach manual review. Integrate with national data sources like Yakeen and Masdr for enhanced identity verification and accuracy in claims processing.
Auto-adjudication Engine
Automate claims adjudication by configuring custom rules to assess low-risk claims for instant approvals. Enhance process accuracy by employing AI models to assess compliance with local health insurance regulations and ensure alignment with policy terms approved by CCHI.
Unified Claims Workbench
Access a centralized platform consolidating all claims activities, from claim receipt to settlement. Empower claim adjudicators to review, analyze, and manage cases effectively using a single interface, with integrated support for payment processing through MADA, UR Pay, STC Pay, and SADAD for seamless claims settlements.
Horizontal Platforms for Insurance Providers
Solution Built On NewgenONE Platform for Health Insurance
Success Stories
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