xRM Formula #293 - Rules to Process Potentially Fraudulent Claims on Service Bus Queue

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Overview

This article covers the setup required to configure access to and from an Azure Service Bus Queue. In this example we will be working with Dental Claims. The claims are created on an external system and then passed onto an Azure Service Bus Queue.

From the Queue, a North52 formula will pick up the messages, create the required claims and claim detail records. This is part of a broader automated claims processing system, however these records are to be manually reviewed after the automated process, as they are for reviewed for potential fraud based on potentially conflicting or otherwise non-standard claims.

The following steps are explained:

Setup of Service Bus Queues
Add data onto the Queue
Reading the Queue
Creating the Record

Service Bus

The service bus is configured on Azure Portal. When it is created we use the Shared access policies to retrieve the RootManageSharedAccessKey. This gives us authorization to send, manage and listen to the service bus

Next we create the Queue. In this example we have created the FraudReview queue.

Accessing of the queue for the end user is done from an Agent Dashboard

Agent Dashboard

Adding Data to Queue

We can use the Service Bus Explorer to put messages on the queue for testing

We create a JSON object like the following example:

{
  "claimid": "123",
  "claimdate": "2025-07-01",
  "patientid": "12345",
  "procedures": [
    {
      "procedureid": "032",
      "date": "2025-06-21"
    },
    {
      "procedureid": "019",
      "date": "2025-06-11"
    }
  ]
}

The JSON object contains the following:

claim id
a patient identifier
an array of the procedures that are part of the claim
- including the dates of the procedures and the procedure identification numbers

Reading the Queue

To read the queue we have created a North52 Formula of type ClientSide - Calculation

This allows us to invoke the formula from a ribbon command - Fraud Claim Review

The ribbon command is configured on the Claims List view, using North52 Quick Ribbon. This allows us to easily invoke a North52 formula from the command bar.

When the Ribbon Command is clicked it triggers the formula Fraud Claim Review

North52 Formula

The Formula is broken down into logical steps which you can see listed on the Decision Sheets on the side of the Decision Table.

First we peek the queue to see if there are any messages waiting
1. If no message is present on the queue, then we exit the formula and alert the user that nothing is present
Since the message is in JSON, we then parse the relevant information
Using the data we create the claim, using information from both the received JSON, and by looking up further information inside Dataverse
Then we loop over the procedures listed in the JSON, and create the Claim Details and associate them with the newly created claim
Once processing is complete, we then remove the queue message.
Finally we open the newly created claim for the end user