Decision Models for Medical Claim Processing

DMCommunity.org Challenge May-2022 still has no submitted solutions. I knew that the problem is not as simple as it sounds because we, at OpenRules, have quite a few claim processing customers, whose decision models address similar and much more difficult problems. When I tried to create a decision model for this challenge, I quickly got a solution that still produced these errors while processing a test-claim:

[E71.313] cannot be reported together with [E72.3]
[E72.3] cannot be reported together with [E71.313]

But the challenge specifically required not to produce duplicate errors. Trying several decision modeling approaches, I built a few “tried-and-failed” decision models before I came up with two solutions which I feel comfortable enough to share here.

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Fast Live Support

OpenRules, Inc. offers fast support online sessions to help you to start working with OpenRules or to address your technical problem.  Upon your request, an OpenRules expert will send you an invite to a remote-support session addressing your particular problem by studying it together with you on your own computer. Anytime you also may order a paid fast-support service that costs only $60.00 USD for up to a 1 hour support session. Link

How Decision Tables work with Big Datasets

Decision tables is the most popular mechanism for representation of business logic – no wonder they play the major role in the DMN standard. However, when it comes to analyzing large amount of data, standard decision tables may not be the best way to do it. In this post, I’ll describe a much better approach implemented in OpenRules.

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