20 Core Modules

Enforces SAMA tariffs, validates diagnoses against ICD-10 codes, applies CCSA clinical protocols, and validates procedures against NAPPI before authorisation. Integrates with every clinical service via event-driven Pub/Sub messages.

Handles the full pre-authorisation lifecycle — from initial L1 automated assessment through L2 clinical nurse review to L3 specialist medical advisor decision. Configurable auto-approval rules reduce manual touch-points for routine procedures while ensuring complex cases receive appropriate clinical scrutiny.

Manages the complete hospital episode — from admission notification and DRG classification through length-of-stay monitoring, theatre benefit management, prosthesis basket management, and planned discharge coordination. Integrates with the Clinical Rules Engine for real-time benefit limit validation.

Processes medical invoices line-by-line against the applicable SAMA tariff schedule, checking for duplicates, unbundling violations, upcoding patterns, and procedure-diagnosis mismatches. Produces a payment recommendation with itemised adjustments and audit notes for every line. High-cost referrals routed to Medical Advisory.

Routes complex clinical decisions to appropriate medical advisors based on specialty and availability. Manages the complete advisory lifecycle — request, assignment, review period, outcome recording, and feedback to the originating workflow — with full audit trail. Integrates with Specialties & Networks for routing.

Manages the complete clinical case lifecycle across three case types — in-hospital (admitted patients using Hospital Benefit), field (mobile case managers at accident scenes using Geo-Mapping), and office-bound (telephonic management). Automated 72-hour notification SLAs, MDT coordination, and real-time status dashboards.

Implements serious injury threshold assessment using AMA Guides WPI methodology. Guides assessors through the body system assessment process, calculates combined WPI scores, manages supporting medico-legal documentation, and produces the official serious injury determination report with full evidentiary chain.

Calculates the present value of future medical costs for 67 baskets of care — using age-adjusted life expectancy tables, treatment cost indices, medical inflation factors, and actuarial discount rates. Produces an itemised future medical expense schedule for legal and settlement purposes.

Reconstructs and validates past medical expenditure by correlating historical invoices against the applicable SAMA tariff schedule for each period, ICD-10 diagnosis codes, and entitlement rules. Identifies over-payments, gaps in treatment records, and produces an auditable expense schedule.

Captures pre-hospital emergency data — ambulance crew details, scene assessment, triage classification (START/JumpSTART), treatment administered, scene-to-hospital transfer route, and handover records. Feeds directly into in-hospital admission workflows to ensure continuity of care data.

Validates prescriptions against NAPPI codes, enforces generic substitution rules and formulary restrictions, applies ATC drug class risk classification, and validates pricing against the Single Exit Price schedule. Integrates with the Clinical Rules Engine for drug-diagnosis appropriateness checking.

End-to-end management of HPCSA professional conduct matters — from complaint intake and investigation through evidence management, hearing scheduling, legal representation tracking, and outcome recording. Automated workflow ensures no step is missed and all HPCSA procedural requirements are met.

A React + TypeScript portal that gives registered healthcare providers direct access to the platform — submit pre-authorisation requests, track claim status in real time, upload supporting clinical documentation, manage practice details, and receive automated status notifications via the Communication Module.

Empowers members with transparent, 24/7 access to their claim journey — submit medical expense claims, view real-time case status, upload required documents, access communication history, and request assistance. Designed for accessibility and low-bandwidth conditions.

Event-driven communication engine integrated with Twilio and Infobip, delivering member and provider notifications across SMS, WhatsApp, and email channels. Templated message management, delivery tracking, and SLA breach alerts are fully configurable per workflow stage. Language detection for multilingual South African audiences.

Exports all claims, case management, and clinical data to BigQuery for large-scale analytics. Pre-built Power BI dashboards cover claims throughput, pre-auth SLAs, fraud risk distribution, and provider performance. The DRG classification tool supports hospital episode cost benchmarking. Scheduled BigQuery reports via the Reporting BI service.

A full-featured React Native mobile app for iOS and Android providing field case managers, providers, and members with on-the-go access to the platform. Offline-first Redux architecture ensures functionality in low-connectivity environments. Features biometric authentication, push notifications, camera-based document capture, and geo-mapped case management.

Applies a configurable rules engine and statistical anomaly detection to generate a 0–100 fraud risk score per claim and per provider. Builds longitudinal provider behaviour profiles to detect pattern changes. Automatically flags high-risk claims for investigation and triggers the Medical Advisory Process for review. ML client adapter for advanced detection models.

Manages the full lifecycle of specialist and sub-specialist network panels — credentialing, directory maintenance, SLA performance tracking, expert appointment scheduling, and network gap analysis. Integrates with the Medical Advisory Process for specialist referral routing and Geo-Mapping for location-based provider searches.

Provides geospatial context across the platform — display the nearest in-network providers to an incident scene, visualise provider network coverage gaps, capture GPS coordinates at incident scenes via the mobile app, and support field case managers with routing to treating facilities. Integrates with EMS Data Management and Case Management.