GCI Rules Engine is a built-in component of the myCARE suite that, amongst others, help identify, register, classify, define, build and manage the application of these healthcare and insurance rules. The engine helps verify consistency in use, manage relationships between multiple rules within complex health care and insurance environments.
The engine provides ultimate flexibility to define any and all rules, conditions, processes, alerts and workflows that enable flawless control of healthcare and health insurance with minimal or no IT or human intervention.
- Ability to translate insurance contracts line by line.Diagnosis based exclusion.
- Handles Exclusions, Deductibles, Coverage etc.
- Specific Requirements like Deductibles on Gross, Deductibles on Net.
- Patient Level Policy definition to handle Eligibility and Charity Patients.
- Multiple payor for single patient.
- Ability to define Rules Based on any information and combination
- Service group, Category, Item Code
- Medicine Generic, Medicine Form, Medicine Category, Medicine Code
- Patient Sex, Patient Age, Patient Nationality etc.,
- Diagnosis Code
- Doctor Specialty, Doctor Sub Specialty, Doctor Type
- Encounter Type (Inpatient, Outpatient, ER)
- Bill value and more