How to Make Unstructured Payment Rules Queryable for Explainable Claims Review

The Previsant Insights platform leverages Memgraph to address the complexity of payment integrity by transforming unstructured payment rules into structured, queryable data for explainable claims review. Through the ingestion and extraction of source documents, the platform identifies rule entities and their relationships, which are then stored in Memgraph, allowing analysts to query and apply rule knowledge to claims with supporting evidence. The system incorporates various querying modes, including RAG, graph, and hybrid, to address different aspects of the workflow, and emphasizes the importance of a well-defined graph model for effective rule application. Human oversight remains crucial in the rule management process to ensure accuracy and relevance, preventing errors that could lead to incorrect claims denial. This methodology, demonstrated in a Medicare Supplement payment scenario, is applicable beyond healthcare, proving beneficial in any domain where decisions are contingent on complex rule sets embedded in documents.

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