Automate Claims Validation
and Strengthen
PMB Compliance
Stop chasing coding errors and rule exceptions.
Health Code Index brings automated clinical coding validation, PMB/DTP rule enforcement and fraud detection directly into your claims process — so your team spends less time reworking and more time improving member outcomes.
The Challenge: Manual Validation Slows Everything Down
Even the best adjudication systems still rely on manual or inconsistent rule checks. That leads to:
- Delayed payments and member frustration.
- Disputes over incorrect or missing codes.
- Rising administrative costs and compliance risk.
Manual validation doesn’t scale. HCI fixes that — instantly.
The HCI Solution: Automated Rule Application
We integrate seamlessly into your existing claims system to validate every case at the point of submission, before it reaches adjudication.
How it Works:
The claim is submitted to your system.
Any inconsistencies are flagged instantly — not days later.
HCI automatically validates CPT-4, ICD-10, and RPL codes for clinical and billing appropriateness.
Scheme-specific tariff rules and PMB/DTP pairings are applied in real time.
"One engine applies every rule, every time — automatically."
Benefits for Medical Schemes
Outcome
What You Get
What You Get
Key Functions at a Glance
PMB & DTP Compliance
Automated notification and validation against Prescribed Minimum Benefits and Diagnosis–Treatment Pairs.
Tariff & Payment Arrangement Validation
Applies custom tariff and specialist payment rules defined by your scheme.
Clinical Cross-Match Validation
Ensures ICD-10 and CPT-4 procedure codes are clinically appropriate and consistent.
Fraud, Waste & Abuse Detection
Flags rule breaches, duplicates, and invalid modifier use automatically.
ICD-11 Readiness
Future-proofed for the next generation of coding standards.
Results You Can Measure
30-40%
Claim rework reduction
2x faster
Adjudication speed
25%
Administrative overhead
50%
Provider dispute volume
“After implementing HCI, one major scheme ‘discovered’ they reduced adjudication turnaround by 45% and achieved full PMB compliance across all claims.”
Easy Integration, Zero Maintenance
- One-time API connection to your claims or fund management platform.
- SpesNet handles all rule and tariff updates daily.
- No ongoing development, hosting, or administration required.
- Fully POPIA-compliant and audit-ready at all times.
Compliance & Governance
HCI enforces every applicable rule automatically:
- Doctors Billing Manual (DBM)
- CPT-4 and ICD-10 Guidelines
- Prescribed Minimum Benefit (PMB) Rules
- Scheme-specific tariffs and payment arrangements
Audit logs and version control are retained for every rule applied, giving you full traceability for internal and regulatory audits.
Trusted by South Africa’s Leading Medical Schemes
“The validation accuracy and PMB alignment have
transformed our operations.
We’re processing faster, more accurately, and with fewer member complaints.”
– Head of Claims, Coverdis Medical Scheme
Ready to Modernise Your Claims Validation?
Streamline adjudication. Improve compliance. Cut operational costs.
Join South Africa’s most advanced funders who trust Health Code Index to power their validation workflows.