Smartchoice Claims

From Ingestion to Settlement, Completely Synchronised

Claims adjudication is the financial and operational heart of medical scheme administration. When legacy platforms rely on batch-delayed lookups, rigid hard-coded rules, or fragmented databases, operations teams face crippling backlogs, high dispute rates, and unchecked financial leakage.

Smartchoice Claims is a high-throughput, rule-governed engine that unifies real-time EDI switch intake, automated clinical rule evaluation, and dual-run financial balancing, reconciling every settlement against its source ledger. Built for transparent operational governance, it lets claims managers automate routine line items instantly while routing complex cases to specialist assessors with complete line-item telemetry.

What Your Team Can Do

Automated Validation Against Master Reference Data
Verify incoming transactions instantly against live practitioner registries (BHF/PCNS), active beneficiary eligibility, contracted DSP networks, and scheme benefit options—either natively across the Smartchoice suite or via secure REST APIs to your existing core databases.

Intelligent Exception Queues & High First-Pass Yield
Maximise straight-through processing (STP) with deterministic adjudication logic. Automatically route genuine anomalies—unmapped tariffs, missing clinical pre-authorisations, complex PMB hospital cases—to specialised assessor worklists with side-by-side line-item visibility and decision prompts.

Proactive Duplicate Interception & Clean Adjustments
Prevent financial leakage with real-time lookbacks against settled claims history. The system flags identical service dates, overlapping hospital stays, unbundled consultation codes, and frequency cap violations before payment release. Execute re-adjudications, partial adjustments, and reversals with full audit lineage.

Interoperable Tariff Pricing & Financial Telemetry
Interface smoothly with major South African EDI clearing switches and clinical pricing tools. Generate electronic remittance advices (ERAs) automatically, manage member savings deductions versus risk pool allocations, and stream live throughput metrics to executive operations dashboards.

How It Connects

Smartchoice Claims is the central operational component of the complete Smartchoice Health Administration Suite, interacting seamlessly with Smartchoice Membership, Provider, Contracts, and Exchange.

Alternatively, it deploys as a modular adjudication and exception gateway layered over existing legacy administration platforms. Downstream banking interfaces, batch settlement payment runs, and provider payment rails are configured to match your scheme's exact financial governance and reconciliation protocols.

Engineered for South African Healthcare Funders

Configured specifically for the statutory mandates and operational complexities of the South African medical schemes market:

• Local Coding Frameworks: Native support for Board of Healthcare Funders (BHF) practice numbering, ICD-10 clinical coding, Complete CPT/CCSA procedure tariffs, and NAPPI pharmaceutical registries.
• Prescribed Minimum Benefits (PMBs): Automated PMB rule evaluation, Chronic Disease List (CDL) benefit routing, and Diagnosis and Treatment Pair (DTP) matching to eliminate non-compliant short-payments.
• Pre-Authorisation Alignment: Real-time reconciliation against hospital utilisation authorisations, designated clinical protocols, and length-of-stay thresholds.
• Auditable Section 59 Due Process: Objective, plain-language discrepancy reasons with timestamped audit trails ensure regulatory compliance and procedural fairness during provider payment reviews.
• POPIA-Compliant Governance: Granular access permissions and data masking safeguard sensitive clinical diagnosis codes and member health records.