Linked Data Integration for Health Insurance

Health Insurance Insights streamlines the process for defining medical consistency rules.

The system automatically discovers expert validated medical information in highly trusted data sources approved by the medical regulation authorities. The identified medical information is formalized as reusable facts that serve as a basis for medical expert validation rule definition. Health Insurance Insights tracks the constantly changing data by recording provenance and can provide detailed audit logs.


According to the Centers for Medicare and Medicaid, spending for health services will continue to grow by close to 6 percent per year through 2019. By then, health-care spending will total $4.5 trillion and account for 19.3 percent of US GDP.

The payers in this process are always trying to reduce the amount of the money spent but at the same time to ensure that the necessary medical therapies and appropriate levels of care are delivered to the patients. As the coverage of the plans is extended and new procedures and treatments are included, the amount of information which needs to be processed and validated increases. This makes impossible the manual processing of generated medical claims and the management and resolution of inconsistencies. What is required is a new, automatic approach to match billable activities with the medical necessities and recommendations by regulators.


Health Insurance Insights provides:

  • Efficient medical consistency rule definition to support claim review process.
  • Automatic high-precision pre-processing and extraction of structured information for prescription drugs (including administration routes and package forms); covered indications (described with both medical codes and narratives), treatment phases and recommended treatment (administration amount and form, up-take regime, treatment duration, population group in scope, co-treatment drug)
  • Coverage of main trusted medical information sources, like Healthcare Common Procedure Coding System (HCPCS); Nation Coverage Determination (NCD); Local Coverage Determination; Prescription Drug Labels (NLM NIH DailyMed); Current Procedural Terminology (CPT)
  • Flexible formalization of the claim entities to any preferred ontology (HCPCS, NDC or ATC codes for prescription drugs; ICD9, ICD10 or SNOMED codes for indications)
  • Mechanism to define and maintain custom vocabularies/ontologies and semantic mappings to available public sources (ICD9, ICD10 or SNOMED).
  • An intuitive interfaces for expert curation and validation of automatically extracted information for drug indication and defined recommended drug dosage.
  • Customizable calculation in the background of parameters, required for the definition of validation rules (e.g. “drug maximum daily dosage”)

Incorrect treatment identification

Very often, mostly due to technical mistakes of staff, claims do not contain information about the diagnosis or the treatment is not approved for the stated in the claim diagnosis. Based on the expert validated information in Ontotext Health Insurance Insights, the system is able to define rules for each drug and the corresponding valid treatments.

High-cost drugs billing errors

There are thousands of drugs each covering different indications and recommendations for appropriate use and dosage. Billing errors, due to inappropriate coding of drug prescription, comprise significant portion of the overall health insurance overpayments billed to the insurer. Ontotext Health Insurance Insights helps to define rules for monitoring of billed units versus administered units, based on trusted drug administration information sources.

Injectable drugs

Most of the injectable drug products are shipped with different product form volumes. Claims do not always list the optimal drug product form volumes required for the administration of the maximum allowed prescription dose. Ontotext Health Insurance Insights can define rules for the identification of such claims and to provide a defendable proof based on trusted sources.

Trusted Medical Sources

Health Insurance Insights covers the main regulatory approved data sources for prescription drugs and medical treatment information – HCPCS, NCD, LCD, NLM NIH DailyMed and CPT. New sources can be added easily and can be mapped to the currently supported data.

Semantic Knowledgebase

Аll extracted knowledge is loaded in Health Insurance Insights semantic knowledge base and the relations between the entities are modeled in a way to allow definition of abstract validation rule patterns forming the Clinical Policy Library (e.g. “each prescription drug must have one or more indications” or “each prescription drug must have a maximum daily dosage”)

Rule Library

All extracted and formalized data is used to populate the model in the semantic knowledge base and the defined validation rule patterns. The system can generate a library of clinical policy rules which can validate the claims for a certain health insurance company.

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