Question

Verifying eligibility for copayment exemptions is an administrative burden for health insurance providers and is highly prone to errors.

• Nested conditions: Calculating the copayment threshold depends on complex factors (gross income, household size, chronic conditions, age).
• Unstructured data: Insured individuals often submit supporting documents (pay stubs, medical certificates, receipts) in a wide variety of formats and qualities.
• High manual effort: Case workers must manually transfer data from documents and manually validate complex calculations.

Solution

We have automated the process using a combination of modern data extraction and rule-based AI.

• Intelligent extraction: An AI-based tool reads unstructured documents and automatically populates the digital application form.
• Digital Logic Map: Using ARUM, the entire set of rules governing copayment exemptions was visualized and stored as the logical foundation for the decision-making tool.
• Rule AI & Simulation: The automation was implemented using Rule AI and thoroughly tested in advance through simulated test cases to ensure 100% accuracy of the decisions.

Outcome

Automation leads to a noticeable speedup for health insurance companies and their policyholders.

• Batch processing available: Standard cases can be processed fully automatically (“in the background”) thanks to high-quality data extraction and clear logic.
• Error-free calculation: Rule AI guarantees precise determination of the individual coverage limit (1% vs. 2%) without manual calculation errors.
• Shorter wait times: Insured individuals receive their exemption card much faster, which increases customer satisfaction and reduces the need for follow-up phone calls.