{"head":{"title":"How to Build a Claims Management System | OceanLab","description":"How to build a claims management system: modules, architecture, data model, integrations, compliance, a phased plan and what drives the cost.","canonical":"https://oceanlab.in/build/claims-management"},"slug":"claims-management","featured":[{"meta":{"slug":"kittiwake","industry":"insurance","projectType":"AI claims intake","country":"gb","tags":["insurtech","ai","enterprise"],"compliances":["FCA ICOBS 8","FCA Consumer Duty","FCA FG21/1","CIDRA 2012","Insurance Act 2015","UK GDPR Article 22","Data (Use and Access) Act 2025","EU AI Act","FCA DISP"],"cover":{"src":"/case-studies/kittiwake/01-home.png","width":1440,"height":1000}},"text":{"en":{"title":"Kittiwake - AI Claims Intake with a Person Behind Every Decision","description":"Designed and built a clickable claims intake console for a UK motor and home insurer: AI reads the customer's story and photos, extracts the facts, drafts a damage estimate and suggests a triage route with its reasons, while a named person confirms cover, routes the claim and makes every call that could go against the customer.","category":"Insurance / AI Claims Intake","client":"Brackenmoor Insurance"}}},{"meta":{"slug":"qistas","industry":"insurance","projectType":"Health claims adjudication","country":"sa","tags":["insurtech","healthcare","enterprise"],"compliances":["Cooperative Health Insurance Law","CHI Unified Health Insurance Policy","NPHIES (HL7 FHIR)","ICD-10-AM and SBS coding","SCFHS clinician registration","PDPL"],"cover":{"src":"/case-studies/qistas/01-home.png","width":1440,"height":1000}},"text":{"en":{"title":"Qistas - Health Claims Adjudication with an Explanation on Every Line","description":"Designed and built a clickable claims adjudication platform for a Saudi cooperative health insurer: claims arrive through NPHIES, from member reimbursements or on paper, a rules engine decides each line with a trace and a provider explanation in Arabic and English, and only uncertain lines reach a medical reviewer.","category":"Insurance / Health Claims Adjudication","client":"Hadaba Cooperative Insurance"}}},{"meta":{"slug":"headgate","industry":"healthdata","projectType":"Claims & EHR integration API","country":"us","tags":["healthcare","enterprise"],"compliances":["CMS-9115-F","CMS-0057-F","HIPAA Privacy and Security Rules","HIPAA X12 transactions","HL7 FHIR R4 and US Core","SMART App Launch","FHIR Bulk Data","Da Vinci CRD, DTR and PAS","CARIN Blue Button"],"cover":{"src":"/case-studies/headgate/01-home.png","width":1440,"height":1000}},"text":{"en":{"title":"Headgate - FHIR Interoperability API Platform for Claims, Clinical Data and Prior Authorization","description":"Designed and built a clickable console for the FHIR APIs a US regional health plan must run under federal interoperability rules: API health across Patient Access, Provider Directory, Formulary, Provider Access, Payer-to-Payer and Prior Authorization, a security review queue for third-party apps, and one clock for every prior authorization request, however it arrived.","category":"Health Data / Interoperability","client":"Juniper Basin Health Plan"}}},{"meta":{"slug":"sotdae","industry":"ai","projectType":"Claims processing agent","country":"kr","tags":["ai","insurtech","enterprise"],"compliances":["Insurance Business Act","Financial Consumer Protection Act","PIPA","Credit Information Use and Protection Act","AI Basic Act","Insurance fraud prevention act","OWASP Top 10 for LLM Applications"],"cover":{"src":"/case-studies/sotdae/01-home.png","width":1440,"height":1000}},"text":{"en":{"title":"Sotdae - Travel Insurance Claims Agent with Human Decisions and Cited Clauses","description":"Designed and built a clickable claims processing agent for a Seoul travel insurance agency: it takes claims in by chat or email, reads receipts and medical reports, checks cover against the policy wording in force on the travel date and writes a recommended decision with the clauses it relied on, while adjusters approve every payment and only people with decline authority can decline.","category":"AI Agents & Automation / Claims Processing","client":"Byeolbit Travel Cover"}}}]}