Overrides are safety checks that ensure the final decision aligns with business policy and practical reality.
Chronic Disease Downgrade
Automatically reduces the risk level for routine chronic condition claims that meet low-risk criteria.
High Exclusion Priority
Ensures claims with very high exclusion rates remain prioritised for review, regardless of other downgrade rules.
Determine how risk scores are categorised into Critical, High, Medium or Low priority for investigation.
Claims with Inappropriate Treatments
Claims with Excessive Charges
Define how different fraud indivators contribute to the overall risk score. Adjust weightings to prioritise statistical anomalies, business rules or benchmarking signals.
Claims with Inappropriate Treatments
Global Anomaly Weight
Controls how strongly the system prioritises claims that are statiscally unusal overall.
Peer Deviation Weight
Controls how strongly the system flags claims that are stand out within their peer group.
Association Rules Weight
Controls how strongly the system prioritises clinically inconsistent prescriptions.
Pair Rarity Weight
Controls how much rare treatment combinations impact the fraud score.
Claims with Excessive Charges
Benchmark Rules Weight
Controls how strongly explicit overcharging rules infuence the final score.
Extreme Value Anomaly Weight
Controls how strongly the system flags claims that are stand out within their peer group.
Expected Charge Deviation Weight
Controls how strongly the system prioritises clinically inconsistent prescriptions.
Define the minimum score required for each detection method to count as a confirmed fraud signal
Claims with Inappropriate Treatments
Global Anomaly Weight
Sets the minimum level of abnormal behaviour required for the system to count it as a flag.
Peer Deviation Weight
Sets how much a claim must stand out from its peer group before it counts as a flag.
Claims with Excessive Charges
Rules Flag Threshold
Sets how strong a pricing rule breach must be before it counts as a flag.
Extreme Value Anomaly Flag Threshold
Sets how unusual a claim's pricing pattern must be before it counts as suspicious.
Expected Charge Deviation Threshold
Sets how far a claim must exceed predicted charges before it counts as overbilling.