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PolicyLinc Agent

Overview

PolicyLinc is BrainSAIT's AI agent specialized in payer policy interpretation and compliance. It reads and understands insurance policy documents, extracts coverage rules, and matches them against claims to ensure policy compliance.

Core Capabilities

1. Policy Document Processing

Supported Formats: - PDF policy documents - Word documents - HTML web pages - Structured data feeds

Processing Functions: - OCR for scanned documents - NLP for text understanding - Entity extraction - Rule identification

2. Coverage Rule Extraction

Extracted Elements: - Covered services - Exclusions - Limitations - Prior authorization requirements - Copay/coinsurance rules - Network restrictions

3. Claim-to-Policy Matching

Validation Points: - Service coverage verification - Medical necessity alignment - Frequency limitations - Age/gender restrictions - Network provider checks

Architecture

graph TB
    A[Policy Documents] --> B[Document Processor]
    B --> C[NLP Engine]
    C --> D[Rule Extractor]
    D --> E[Policy Knowledge Base]

    F[Claim Data] --> G[Claim Analyzer]
    G --> H[Rule Matcher]
    E --> H
    H --> I[Compliance Report]

Use Cases

Pre-Service Verification

Scenario: Check coverage before scheduling service

Process: 1. Input: Service codes, diagnosis, patient coverage 2. PolicyLinc queries applicable policies 3. Returns: Coverage status, requirements, patient responsibility

Output Example: 

{
  "service": "27447",
  "covered": true,
  "requirements": {
    "prior_auth": true,
    "documentation": ["MRI results", "Conservative treatment record"],
    "network": "in-network required"
  },
  "patient_responsibility": {
    "copay": 500,
    "coinsurance": 0.2
  }
}

Denial Prevention

Scenario: Validate claim before submission

Process: 1. Input: Complete claim with supporting documents 2. PolicyLinc checks all policy rules 3. Returns: Pass/fail with specific rule citations

Appeal Support

Scenario: Build appeal based on policy language

Process: 1. Input: Denied claim and denial reason 2. PolicyLinc analyzes policy for favorable language 3. Returns: Supporting policy clauses and arguments

Policy Knowledge Base

Structure

policy:
  payer: "Bupa Arabia"
  plan: "Gold Plus"
  effective_date: "2024-01-01"

  coverage:
    - category: "Inpatient"
      rules:
        - type: "general"
          covered: true
          auth_required: true
        - type: "exclusion"
          code: "cosmetic"
          covered: false

    - category: "Outpatient"
      rules:
        - type: "general"
          covered: true
          copay: 50

Rule Types

Type Description Example
Coverage Basic service coverage "Inpatient covered"
Exclusion Not covered services "Cosmetic surgery excluded"
Limitation Quantity/frequency limits "2 MRIs per year"
Requirement Pre-conditions "Prior auth for surgery"

Integration

ClaimLinc Integration

PolicyLinc provides policy validation data to ClaimLinc:

sequenceDiagram
    participant CL as ClaimLinc
    participant PL as PolicyLinc
    participant KB as Knowledge Base

    CL->>PL: Validate claim
    PL->>KB: Query rules
    KB->>PL: Applicable rules
    PL->>PL: Match rules to claim
    PL->>CL: Compliance result

API Endpoints

Check Coverage: 

POST /api/policylinc/check-coverage
{
  "patient_id": "123",
  "payer_id": "bupa",
  "services": ["27447"],
  "diagnosis": ["M17.11"]
}

Get Policy Rules: 

GET /api/policylinc/rules?payer=bupa&category=surgery

Key Features

Multi-Payer Support

  • Bupa Arabia
  • Tawuniya
  • GlobeMed
  • Medgulf
  • Other Saudi payers

Version Control

  • Track policy changes over time
  • Apply rules based on service date
  • Alert on policy updates

Conflict Resolution

  • Handle contradictory rules
  • Apply most specific rule
  • Document decision logic

Performance Metrics

Metric Target Current
Policy processing time < 5 min 3 min
Rule extraction accuracy > 95% 96%
Claim matching latency < 500ms 300ms
Coverage prediction accuracy > 90% 92%

Configuration

Payer Setup

payers:
  bupa:
    name: "Bupa Arabia"
    policy_sources:
      - type: "pdf"
        path: "/policies/bupa/"
      - type: "api"
        endpoint: "https://api.bupa.com.sa/policies"
    update_frequency: "daily"

Rule Priorities

rule_priorities:
  1: specific_procedure
  2: procedure_category
  3: general_coverage
  4: plan_default

Best Practices

Policy Maintenance

  1. Regular policy updates
  2. Version history tracking
  3. Change notifications
  4. Rule validation testing

Integration

  1. Pre-service checks
  2. Real-time claim validation
  3. Denial analytics
  4. Appeal automation

Last updated: January 2025