Requirement Summary AI-Based Claims Validation & Analytics SaaS Platform 1. Objective Develop a cloud-based SaaS platform for hospitals that helps manage insurance claims and significantly reduce claim rejections. The platform’s core capability will be a powerful AI-based claim validation system that analyzes claims before submission and identifies potential issues that may lead to rejections or insurer queries. The system should also integrate with insurance/TPA portals to retrieve claim status information and provide rejection and query analytics through dashboards. The platform must support multiple hospitals using a secure multi-tenant architecture. 2. Users The system will be used by hospital staff responsible for insurance claims processing. Users include: • Hospital Billing Team • Insurance / TPA Desk Staff • Hospital Management There will be no external users such as patients or insurance companies accessing the platform. 3. Platform Structure The system should operate as a multi-hospital SaaS platform. Requirements: • Each hospital should have its own secure workspace • Data of each hospital must remain isolated • A central super admin should manage hospitals on the platform 4. User Roles Super Admin Manage hospitals on the platform Monitor system usage Hospital Admin Manage hospital users Monitor hospital claim analytics Billing Executive / Insurance Desk Create and manage claims Upload claim documents View AI validation alerts 5. Claim Management The platform should allow users to create and manage insurance claims. Claim data may include: • Patient details • Admission and discharge information • Diagnosis and treatment details • Insurance provider details • Claim amount and policy information Features include: • Create and edit claims • Save draft claims • Track claim status 6. Document Management Users should be able to upload and manage claim-related documents such as: • Discharge summary • Medical reports • Hospital bills • Pre-authorization approvals Features: • Multiple document uploads • Document checklist • File preview 7. AI-Based Claim Validation (Core Function) The platform must include a powerful AI-based claim validation system, which will be the central component of the platform. The AI system should automatically analyze claims and identify potential issues before submission. Capabilities should include: • Detect missing or incomplete claim information • Identify inconsistencies in claim data • Highlight potential rejection risks • Identify abnormal or suspicious claim patterns • Generate alerts and recommendations before submission The goal of this AI system is to reduce claim rejection rates and improve claim quality before submission to insurers. 8. Integration with Insurance / TPA Portals The system should integrate with insurance provider or TPA portals/sites using hospital credentials. The platform should retrieve claim information such as: • Claim approval status • Claim rejection details • Insurer queries or deficiencies • Settlement details • Claim processing timelines 9. Rejection and Query Analytics The platform should provide analytics based on retrieved claim data. Dashboards should display: • Claim approval and rejection rates • Query or deficiency statistics • Insurance provider performance • Department-wise claim performance • Claim processing timelines Analytics should be presented through visual dashboards with charts and graphs. 10. Reports The platform should generate reports including: • Claim summary reports • Rejection analysis reports • Insurance provider performance reports • Department-wise claim reports Reports should be exportable to Excel or PDF. 11. Security The platform should ensure strong security and data protection. Requirements include: • Secure authentication • Role-based access control • Data isolation between hospitals • Encrypted communication • Regular system backups