Health Insurance Portals

• Self-registration forms tailored to the client segment (individual, corporate), region, language, etc.
• Data capture from forms and document scans using robotic process automation (RPA) and optical character recognition (OCR).
• Automated KYC verification for new members.

Value-adding features:

• Automated processing of digital documents (e.g., proof of identity, residence, occupation) using intelligent image analysis and machine learning (ML) technologies.
• ML-supported validation of data provided by members against reliable sources (e.g., identity or employment databases).
• Members’ e-signature capture and verification.
• Real-time personalized content recommendations for each member.

• Managing and updating personal or business information and billing details via the portal.
• Setting up the preferred language, communication channel, billing method, etc.
• Uploading documents in different formats, including PDF, JPG, PNG, etc.
• Viewing the health policy portfolio and the history of health insurance transactions.
• Configurable notifications to members on the expiring policies, open enrollment dates, due payments, personal and billing info that needs updating, etc.

• Automated search for best-fitting health plans based on user-defined criteria (duration, cost, coverage terms, etc.).
• Side-by-side comparison of coverage details across different plans.
• A self-service premium calculator.
• Filing enrollment questionnaires: describing health conditions, choosing a primary care provider, adding dependents, etc.
• Automated generation of health insurance applications and their instant submission to the insurer.
• Real-time monitoring of the enrollment and health policy issuance statuses.
• Receiving printable digital policies.
• Template-based requests for policy adjustment, renewal, and termination.

Value-adding features:

• Dynamic enrollment questionnaires that auto-adapt depending on the insureds’ declared health conditions (e.g., displaying additional questions for applicants with chronic diseases).

• Support for various payment methods: bank transfer, card, check, digital wallet, etc.
• Real-time processing of payments via the connected payment gateways.
• Notifications to clients on successful and failed payments.
• Scheduled payment retry in case of failure.
• Recurring payment auto-deduction via direct debit for premiums paid in installments.
• Automated payment reconciliation.

Value-adding features:

• Multi-currency payments, including cryptocurrency payments.

• Criteria-based search for suitable healthcare specialists, facilities, and pharmacies across the insurer’s partner network.
• Viewing provider profiles with information on services offered, accepted insurance plans, and referral requirements.
• Checking whether specific medical services, procedures, and prescriptions are covered under the member's current insurance plan.
• Viewing plan-specific coverage details (e.g., copays, deductibles, coinsurance) for different types of medical services.
• Calculating out-of-pocket costs based on the selected service, provider, and location.
• Template-based creation and submission of prior authorization requests (e.g., in case of turning to an out-of-network provider).
• Tracking the status of pre-authorization requests.
• Ability to download or share a digital summary of coverage verification and cost estimate.

Value-adding features:

• Intelligent suggestions on the best-fitting healthcare providers

• Template-based creation of health insurance claims (accepting ICD-10 and CPT codes when provided).
• Instant submission of claims with support for various formats of claim evidence (health test reports, hospital discharge summaries, prescription receipts, medical bills, etc.) to the insurer.
• Alerts on claim filing errors (e.g., missing or incorrectly filed form fields).
• Real-time claim status tracking.
• Receiving explanations of benefits (EOB) and submitting appeals for disputable cases.

• Scheduled notifications to members about recommended health screenings, vaccinations, and medical procedures.
• Interactive tools for members to assess their overall health risks.
• (For behavior-based health insurance) Interactive dashboards displaying health objectives, achievements, and rewards for health-conscious behaviors.

Value-adding features:

• AI-powered suggestions to insureds on the proper steps to mitigate health risks, e.g., adjusting sleep and workout schedule or visiting a doctor.
• Direct access to telemedicine services for health-related consultations.

• Live chat for members to communicate with the insurer’s servicing and support specialists.
• A self-service knowledge base with articles and FAQs about insurance terms.
• Scheduling in-person health payer appointments.

Value-adding features:

• An AI-powered virtual assistant to instantly process users’ support inquiries and help users solve simple operational issues 24/7.

• Rule-based capture and processing of health insurance leads.
• Automated eligibility checks for applicants enrolling in federal insurance programs (Medicaid, Medicare, etc.).
• Instant submission of health insurance applications, supporting documents, and pre-writing files to underwriters.
• Automated generation of personalized customer quotes.
• Real-time tracking of the underwriting progress.
• Template-based creation of health insurance policies and customer invoices.
• Sending health insurance documents to customers via email or instantly printing them.
• Automated reporting of enrollment details to the insurer.
• Live chat to communicate with underwriters, loss adjusters, reinsurers, etc.
• Notifications to agents and brokers on the special enrollment policies nearing the expiration date to initiate interactions with members on the policy renewal.

• Secure, permission-based access for agents and brokers to:
  • Health plan data, policy prices, coverage terms, etc.
  • Member data: policies owned, billing history, claim history, and more.
  • Policyholder agreements and premium statements.
  • Promotional materials: product presentations, brochures, videos, etc.
• Smart search across document content and metadata to quickly find relevant health insurance materials.

Value-adding features:

• Natural language search (using text or voice commands) of the required

• Automated task assignments to health insurance agents based on their qualifications, availability, schedule, location, etc.
• Automated creation and updating of task lists.
• Configurable dashboards providing agents with an overview of scheduled in-person appointments, assigned tasks, their priorities, and deadlines.
• Interactive reporting forms for agents to manually enter and adjust task completion statuses.

• Configurable forms for broker self-registration.
• Uploading broker licenses, professional certifications, and E&O insurance policies.
• Automated verification of broker licenses (e.g., against a NIPR database).
• Rule-based calculation of broker commission.
• Automated generation of commission invoices and invoice sending to the payer.
• Monitoring due and received commissions and payout dates.
• Rule-based commission reconciliation.
• Notifications to brokers on licenses and certificates nearing the expiration dates.

Value-adding features:

• AI-supported fully automated broker onboarding.

• Personal dashboards showing key performance metrics by health plan, period, or customer segment (e.g., new enrollments, quote rate, conversion rate, targets vs. actuals).
• Automated checks for compliance with internal policies and industry regulations.

Value-adding features:

• Real-time alerts on non-compliance cases, e.g., improper insured communication, unverified enrollments, misrepresentation of health plans.

• A centralized knowledge base for agent and broker self-education:
  • Summaries of ACA, Medicare, Medicaid, employer, and short-term plans.
  • HIPAA policies, anti-fraud guidelines, and ethical sales practices.
  • Step-by-step enrollment guides.
  • Claim processing and reimbursement FAQs.
• Agent and broker onboarding tours with content tailored by specialization (e.g., particular health coverage types or customer segments).
• Private forums and discussion boards for agents and brokers.
• (For agents) Rule-based assignment of e-learning programs to particular agents and real-time monitoring of agents’ learning progress.

• Uploading, editing, and publishing informational and promotional content:
  • Health plan details, knowledge articles, data on new products and discounts for members.
  • Health plan summaries, servicing guidelines, compliance policies for agents and brokers.
  • Policy details, enrollment and claim settlement resources for providers.
• Creating and managing custom forms (e.g., member enrollment questionnaires, pre-authorization forms).
• Launching and processing customer experience surveys and polls.
• Content versioning.
• Content categorization and segmentation for various user groups.

Value-adding features:

• AI-supported content translation and localization.

• Configurable dashboards for admins to manage user accounts and monitor user activities on the portal.
• Rule-based approval of new user accounts.
• Automated processing and distribution of user support requests.
• A complete log of user account management activities.

Value-adding features:

• AI-powered straight-through processing of data and documents submitted by users during self-registration and instant notifications on missing, erroneous, or contradicting data pieces.
• AI-powered real-time detection of suspicious user activities that may indicate fraud, e.g., rapid multiple submissions or changes in personal details before filing a claim.

• Configuring user roles and permissions to view, edit, download, and share particular health insurance data and documents.
• Role-based access control.
• Multi-factor user authentication.
• Portal data encryption at rest and in transit.
• End-to-end audit trail of manipulations of user accounts by admins.
• Monitoring the compliance of user activities, data storage, processing, and access procedures with the payer’s internal policies and regulatory rules (e.g., HIPAA requirements for PHI protection).