Transcript:
0:00 claims adjudication processes can be
0:02 very complex and using a business rules
0:04 engine to automate the claims process
0:05 can save significant time reduce errors
0:08 and increase customer satisfaction north
0:10 52's decision suite helps you implement
0:12 complex rules on the microsoft dynamics
0:14 365 platform
0:16 in this video we'll show how an
0:18 automated claims process for dental
0:20 insurance can be implemented using the
0:22 North52 decision suite dynamics 365 and
0:25 powerapps portals
0:27 for a deeper understanding of how the
0:28 business rules logic is implemented
0:30 using decision tables please see the
0:32 associated articles on our support
0:33 portal
0:35 on our support site we've provided rules
0:37 tables for each component of the
0:38 adjudication process these are all based
0:40 on a real policy of an insurance
0:42 provider in europe let's take a look at
0:44 the coverage rules when someone submits
0:46 a claim on the system the very first
0:48 rule applied is to check coverage for
0:50 the treatment and decide whether it is a
0:52 percentage base cover
0:53 if this rule matches we're going to set
0:55 the covered flag to true and the amount
0:58 claimable as a percentage of the claim
1:00 item cost
1:01 additionally there are external and
1:03 internal messages that are shown to the
1:05 customer and recorded in the claim
1:06 detail record
1:08 for each different type of rule set
1:10 we've provided these rules tables and
1:12 then show how these are translated into
1:14 decision tables the articles show how we
1:16 approach this kind of problem and how
1:18 you can join it all together using the
1:19 North52 decision suite within the
1:21 decision tables we can see that we can
1:23 reference specific rules that have been
1:25 defined in systems like azure devops or
1:27 jira let's have a look at the dynamics
1:29 365 model driven app where we have two
1:32 policies for our demo contact one that
1:34 was for last year and one that is for
1:36 this year
1:37 if we go into the policy itself we can
1:39 see it's got a start and end date and
1:41 time but the really important things are
1:43 the coverage and restriction records
1:46 each policy has coverage for specific
1:47 treatments and some of them have
1:49 interval periods
1:51 for example how often does this coverage
1:53 apply for this policy every 12 months
1:56 you can have one crown re-cement and
1:58 there is a 50 coverage if we look at the
2:00 next one
2:01 dental implant treatment again it's for
2:04 a 12-month period there is no limit on
2:06 the number of claims here but there is a
2:08 maximum coverage limit of two thousand
2:10 dollars and coverage is for a hundred
2:12 percent of costs the various coverage
2:14 rules are defined in the remaining
2:15 records and these are used at run time
2:17 to look up and see what is covered and
2:19 determine how much coverage is provided
2:21 on this particular policy similarly with
2:23 the policy restrictions specific
2:25 treatments might have other restrictions
2:26 defined we've got a maximum amount of
2:29 orthodontic treatment and because it
2:30 does not have a start and end date
2:31 defined the restriction means that this
2:33 is the maximum amount that the person
2:35 can receive in their lifetime another
2:37 restriction could be for waiting periods
2:39 for basic treatment types the end date
2:41 is specified as the first of april this
2:44 means that for the first three months of
2:45 this policy no claims can be made for
2:48 basic treatment types once this is all
2:50 in place a user can then come into the
2:52 portal to their policies and create
2:54 claims here we have had two claims
2:56 already for this particular policy let's
2:58 create a couple of new claims and see
3:00 the rules in action we'll choose a
3:02 policy for our user and click submit
3:05 this builds a claim record behind the
3:06 scenes and when the screen refreshes
3:09 there are a number of North52 rules
3:10 happening on the load of the form
3:12 things like our North52 quick tile
3:14 functionality to show progress
3:16 we then add a claim item and select a
3:19 treatment
3:20 say we've got a routine checkup that we
3:22 want to claim for it was on monday the
3:24 13th and it was a hundred dollars so i
3:27 submit this
3:28 the rules are then checked and applied
3:30 and we can see here immediately that
3:32 even though it's got 100 coverage we've
3:34 already claimed this treatment in the
3:36 last 12 months and thus it's been
3:38 rejected perhaps i had a filling done on
3:40 the same day for 120
3:42 when selecting this another field shows
3:44 because it's a toothpaste treatment
3:46 North52's rules are showing and hiding
3:48 these fields on the portal form
3:55 once submitted the rules are applied and
3:56 we get a standard notification saying
3:58 that we've got 70 percent coverage for
4:00 fillings and have already claimed 242
4:03 dollars of the maximum benefit for this
4:04 policy but because i'm still within my
4:07 limit it's been approved when i'm ready
4:09 to submit my claim for assessment i
4:11 check this box and click the update
4:13 claim button the North52 rules apply
4:15 and the claim is processed and because
4:17 our claim has met some certain
4:18 thresholds it has been approved and is
4:21 awaiting settlement skipping other
4:23 stages because it's under a threshold
4:25 i'll go through another scenario to show
4:27 where the claim needs to go through the
4:28 assessment team we'll create another
4:30 claim for the same policy this time i'm
4:33 going to do some emergency treatment
4:37 let's say it was yesterday and for six
4:39 hundred dollars we can see it's got 100
4:41 coverage and i've already claimed 326
4:44 out of my maximum and it's been approved
4:48 when i submit this claim and because
4:50 it's over a threshold we can see that
4:52 the claim has been moved on to the
4:53 pre-assessment stage and will be
4:55 notified of next steps the rules making
4:58 these automated decisions are defined in
4:59 the North52 decision tables the first
5:02 decision table we'll take a look at is
5:04 quite simple and handles the
5:05 pre-assessment checks and automated
5:07 approval it triggers off the claim
5:09 status field and the rules are defined
5:11 in rows four to seven
5:13 taking a look at row four
5:16 we check the claim status as
5:17 pre-assessment
5:19 then check our customer loyalty is
5:20 greater than five years
5:22 then we check our previous number of
5:24 claims are less than seven and finally
5:26 the total claim amount needs to be less
5:28 than five hundred dollars if all
5:30 conditions are met then it will be
5:31 automatically approved if the conditions
5:34 are not met then the claim will progress
5:36 through the standard process that is a
5:38 fairly simple decision table where the
5:40 complexity arises is when determining
5:42 the policy coverage and restrictions and
5:44 the rules for these are defined in this
5:46 formula which has multiple decision
5:48 tables when this formula is executed the
5:50 first thing that happens is that the
5:52 relevant policy coverage policy
5:53 restrictions and previous claims records
5:55 are retrieved and loaded into memory
5:57 what we call North52x cache this allows
6:00 the decision table rules to perform very
6:02 efficiently also in memory and minimize
6:05 database queries the first thing we're
6:07 going to check is the coverage
6:09 the rules look up the treatment that the
6:11 person has specified for this claim item
6:13 and if a policy record is found and it's
6:15 got a percentage coverage specified then
6:17 we're going to say that the coverage is
6:19 true the amount claimable is calculated
6:21 as a percentage of the claim amount and
6:23 then we construct internal messages and
6:25 external messages external messages are
6:27 shown to the end user on the portal and
6:30 internal messages are saved into the
6:31 system for a customer service
6:32 representative to see
6:34 we have different messages because there
6:36 is more detail that we want to record
6:38 for internal use if the policy had
6:40 specified a maximum amount for the
6:41 treatment coverage the amount claimable
6:43 would be calculated using the min of
6:45 function to take either the claim amount
6:48 or the maximum amount whichever is the
6:50 smaller if there was no coverage
6:52 specified for the treatment the covered
6:54 variable is set to false and the claim
6:56 amount set to zero the next set of rules
6:58 to be processed pertain to previous
7:00 claims however the first check performed
7:02 will stop further rules processing if
7:05 the coverage check returned false as
7:07 there is no need to process further
7:08 checks if the treatment is not covered
7:11 this makes the rules execution very
7:13 efficient but if coverage was true we
7:15 need to apply rules pertaining to
7:16 previous claims
7:18 again this is all being driven by
7:20 queries into the system to pull back
7:22 data analyze it in memory and then
7:24 process it against all these conditions
7:26 let's take the rule on row five
7:29 r pre-02
7:31 per tooth treatment with interval period
7:33 and previous claims greater than the
7:34 allowable quantity if there have been
7:36 previous claims for the specified tooth
7:38 with an interval period and the policy
7:40 coverage specifies an interval period
7:42 and a coverage quantity then we check
7:44 the previous claims are greater than or
7:46 equal to the quantity that is specified
7:48 in the coverage
7:49 if all these conditions match then we're
7:51 going to say the claim item is not
7:53 covered by setting the variable to false
7:55 and outputting the following messages
8:00 the remaining rows in this decision
8:01 table cater for different rules
8:03 scenarios you can look in more detail at
8:05 these in the corresponding article on
8:07 our support portal following the
8:08 previous claims checks there are rules
8:11 for the various policy restrictions
8:13 waiting period checks
8:15 treatment maximum benefit checks and
8:18 overall maximum benefit checks these are
8:20 all available on our support portal if
8:22 you'd like to review in more detail once
8:24 all the rules have been processed then
8:26 we update the claim item and claim
8:27 header records to reflect the outcome of
8:29 the rules setting things like the status
8:32 amount claimable and the messages if we
8:34 take a look at the claim record in
8:36 dynamics 365 we can see these changes
8:38 have been saved the claim item status
8:41 and messages
8:43 and here the messages on the claim
8:45 record
8:46 the messages show an audit of the claim
8:48 items added or edited on this claim
8:50 we've shown how we create and process
8:52 claims using the specified rules and
8:54 you've seen that it is reasonably
8:55 complex but how do you ensure that these
8:58 rules are applied consistently
8:59 especially if changes are made to the
9:01 system
9:02 you use North52's test shield of course
9:05 there are about 100 tests to cover all
9:07 the different scenarios and outcomes
9:09 based on different types of policy
9:10 coverage and restrictions for this video
9:13 i'm going to show you one of these which
9:15 tests the coverage 0-1 and previous
9:18 claims 0-6 rules
9:22 we set up a test with test shield we go
9:24 through four stages assemble arrange act
9:27 and assert
9:29 for the assemble stage we define what we
9:31 want to test and you can see here the
9:34 two rules that i want to test and the
9:35 details of these rules are available in
9:38 these linked azure devops work items for
9:40 the arrange stage we define the records
9:42 that need to be created in order for the
9:44 test to be performed the following
9:46 sheets define these records and the
9:48 values set
9:49 we need to create a contact policies
9:52 coverage restrictions a claim and claim
9:55 detail records each row represents a
9:57 record
9:58 test shield makes it easy to create
10:00 these sheets from existing data so
10:02 you're able to set up tests in minutes
10:04 the next stage in a test shield test is
10:06 the act stage this is where manual
10:08 triggers such as user initiated
10:10 workflows can be set up
10:12 for this test all the logic is triggered
10:14 automatically so we do not have any
10:15 steps in the act stage finally we come
10:18 to the assert stage which is where we
10:20 check the values that have been
10:21 automatically calculated by the rules
10:23 engine logic match what we're expecting
10:25 for example is the acclaimable amount
10:28 100 and do the messages match these
10:30 values
10:31 is it going to be approved you would
10:33 normally run this test as part of your
10:35 devops processes but i can manually run
10:37 it here and i'll do that right now to
10:39 show you what happens i click execute
10:41 and test shield is going to create all
10:43 those records in the system and the
10:45 rules will be applied and update the
10:46 records then those updates will be
10:48 checked against the values in the assert
10:50 sheet to see that they are a match if
10:52 there is a failure we will know that
10:54 something has changed and it can be
10:55 investigated once finished we go to the
10:58 source tab and i can see under my test
11:00 run results that i've got 27 passes for
11:02 all the fields that i'm assessing
11:04 if we go in here and have a look at the
11:06 fee the actual was a hundred and
11:08 expected was a hundred therefore that's
11:10 a pass
11:11 to see what has happened behind the
11:13 scenes we can view the records that have
11:14 been created as part of this test we can
11:17 see we've created a test contact and
11:19 we've also got two policies that have
11:20 been created for this test contact
11:23 three claims have been created for this
11:24 test contact
11:26 all that information is being created as
11:28 part of our test and allows us to ensure
11:30 that those claims are processed in the
11:32 way that they should have been
11:35 that concludes our overview into how you
11:36 can build and test complex insurance
11:38 based rules using the North52 decision
11:40 suite if you'd like to know more
11:42 please review the associated articles on
11:44 our support portal and get in touch to
11:46 see how we can help you with your
11:47 complex business rules requirements on
11:49 the dynamics platform