Oracle Insurance Claims Adjudication for Health


Oracle Insurance Claims Adjudication for Health provides automated claims adjudication for the full spectrum of healthcare claims. The application provides comprehensive, out-of-the-box support for a wide range of healthcare claims processes while being flexible enough to allow any healthcare payer to tailor the solution to its specific needs.


  • Evaluates claims in real time based on user-configured rules
  • Sends exceptions to workflow to accelerate manual review
  • Delivers comprehensive support for a wide range of claim types
  • Supports both standard coding terminologies such as ICD-10 as well as custom coding schemes
  • Provides comprehensive visibility of member and family level benefits utilization and provider utilization
  • Offers numerous out-of-the-box integration points
  • Provides highly scalable architecture to support changing organizational needs


  • Helps healthcare payers achieve high rates of auto-adjudication and processing accuracy while realizing significant operational savings
  • Helps ensure that claims are processed and paid more quickly and accurately the first time, improving member, employer, and provider satisfaction
  • Enables payers to quickly introduce new products, reimbursement models, and benefit interpretations to keep pace with evolving marketplace conditions
  • Gives healthcare payers the flexibility to grow their business without concerns for technology constraints
  • Allows payers to mitigate operational risk by pursuing a phased approach to legacy system replacement
  • Enables payers to reduce their reliance on scarce IT resources by authoring easily configured business rules rather than relying on custom coding
  • Makes the consolidation of back-office claims operations easier and more cost effective
  • Improves payers' ability to give members and providers access to information such as utilization and claims history for individuals and families, or details on benefit limitations
  • Provides a consolidated and comprehensive view of benefits utilization even when some claims are processed by other systems