Blaze Advisor Business Rules Management System (BRMS)

1. Blaze Advisor Business Rules Management System (BRMS)

2. Blaze AdvisorIntegration with IFM • Blaze Advisor BRMS provides the capability for non-technical resources to configure and deploy: • Fraud, Waste and Abuse rules on data elements included in the data feeds to/from Insurance Fraud Manager (Professional, Facility) • Capability to implement blues card rules prior to payment • Workflow management rules to more effectively manage the review of individual claims within Insurance Fraud Manager • Rules which manage systemic issues identified by IFM or other means • Blaze is preconfigured to accept your data • Blaze uses existing IFM feeds. No new data feeds required from IT. • Blaze can be expanded to accept ANY data source • Clients can choose to integrate any data source to make a claim payment decision

3. Blaze AdvisorIntegration with IFM Current State Implementation IFM Scoring Engine Client Claim System Dynamic Profile Providers Ratio of X - rays to exams IFM Data Feeds Members $ billed vs. peers Claims Derive Procedure mix vs. Predictive Scores and Powerful peers Reasons Models Variables Dental Max single - day activity Ÿ Ÿ Pharmacy Ÿ Profile Variable N IFM User Interface Decision (Pend, Deny, Pay)

4. Blaze AdvisorIntegration with IFM The addition of Blaze Advisor provides a platform to close FW&A gaps through business rules IFM Scoring Engine Client Claim System Dynamic Profile Providers Ratio of X - rays to exams IFM Data Feeds Members $ billed vs. peers Claims Derive Procedure mix vs. Predictive Scores and Powerful peers Reasons Models Variables Dental Max single - day activity Ÿ Ÿ Pharmacy Ÿ Profile Variable N IFM User Interface Rules, Strategies, Models Decision (Pend, Deny, etc) Blaze is pre-configured to ‘plug and play’ with IFM, using IFM data feeds and advice files

5. Blaze AdvisorIntegration with IFM Blaze Advisor’s Rule Management interface allows non-technical users to deploy rules IFM Scoring Engine Client Claim System Dynamic Profile Providers Ratio of X - rays to exams IFM Data Feeds Members $ billed vs. peers Claims Derive Procedure mix vs. Predictive Scores and Powerful peers Reasons Models Variables Dental Max single - day activity Ÿ Ÿ Pharmacy Ÿ Profile Variable N IFM User Interface Rules, Strategies, Models Decision (Pend, Deny, etc) Advice File (Pend, Deny, Pay) Fraud Rules Waste Rules Abuse Rules Policy Gap Rules Analyst Rule Control Define

6. Blaze AdvisorIntegration with IFM Additional data sources can be leveraged to analyze and decision claims Other Data Sources IFM Scoring Engine Client Claim System Dynamic Profile Providers Ratio of X - rays to exams IFM Data Feeds Members $ billed vs. peers Claims Derive Procedure mix vs. Predictive Scores and Powerful peers Reasons Models Variables Dental Max single - day activity Ÿ Ÿ Pharmacy Ÿ Profile Variable N IFM User Interface Rules, Strategies, Models Decision (Pend, Deny, etc) Advice File (Pend, Deny, Pay) Fraud Rules Waste Rules Abuse Rules Policy Gap Rules Analyst Rule Control Define

7. Blaze AdvisorIntegration with IFM Learnings from both IFM and Non-IFM findings can be deployed via Blaze Adaptive Loop Other Data Sources IFM Scoring Engine Client Claim System Dynamic Profile Providers Ratio of X - rays to exams IFM Data Feeds Members $ billed vs. peers Claims Derive Procedure mix vs. Predictive Scores and Powerful peers Reasons Models Variables Dental Max single - day activity Ÿ Ÿ Pharmacy Ÿ Profile Variable N IFM User Interface Rules, Strategies, Models Decision (Pend, Deny, etc) Advice File (Pend, Deny, Pay) Deploy IFM findings Fraud Rules Waste Rules Abuse Rules Policy Gap Rules Non- IFM findings Analyst Rule Control Define

8. Blaze AdvisorIntegration with IFM Rule Examples: • Blues Card Edits • High Unit Rules • Social Security Death Master • Provider Black Lists • Always Approve • Always Deny • Derived data based on complex calculations/formulas.