Administration
Enterprise health insurance and medical aid administration
NEXMAS runs the administrative core of a scheme: claims, members, benefits and the audit trail behind every decision, driven by a rules engine that combines rule-based logic with artificial intelligence.
- Platform
- NEXMAS
- Built for
- Medical aid providers and health insurers
- Delivery
- Rented as a managed service
Where NEXMAS fits
NEXMAS is used by medical aid providers and health insurers. It covers the daily work that decides whether a claim is paid correctly, a script is dispensed safely, or a member stays on the scheme.
- Automated claims processing
- Rules engine
- AI analytics and insight
- Member and beneficiary management
- Chronic register
- Scheme and benefits administration
- Reporting and audit
Capabilities
Each working area below is built around a task the team performs every day.
Automated claims processing
Claims land in one intake queue, scheme rules are applied on entry, exceptions route to a review queue, and every claim keeps a status the member can be told.
Rules engine
Claims and membership processing run on a rules engine built from explicit rule logic, so a policy change is a rule update rather than a rebuild, and the same engine stays efficient as volumes grow.
AI analytics and insight
Artificial intelligence reads claims and membership activity to produce analytics and insights, feeding executive management with real-time strategic recommendations and flagging risks early enough to act on.
Member and beneficiary management
Registration, dependants, membership lifecycle and eligibility sit on one record, with member status and benefits verifiable in real time at the point of service.
Chronic register
A chronic register sits inside NEXMAS for managing chronic clients: registered conditions, authorisation status, repeat scripts and review dates, visible to assessors and service teams on the same member record.
Scheme and benefits administration
Benefit structures, waiting periods, authorisations and provider records are configured in one place and applied consistently at adjudication.
Reporting and audit
Turnaround reporting, exception reports and a full activity trail show who decided what, on which rule, and when.
Rules engine
Rule-based logic and AI, working on the same decisions
The NEXMAS rules engine is built from your automated claims and membership processing rules. Rule logic handles the predictable decisions quickly and consistently, artificial intelligence reads the patterns around them, and the two together give executive management a live view of what the scheme is doing.
Rule-based technology
Claims and membership processing rules are expressed as explicit logic, so the engine applies the same decision every time and the outcome can be explained to an assessor, an auditor or a member.
Efficient and flexible logic
Adding a benefit limit, a waiting period or an authorisation condition is a rule change rather than a rebuild, which keeps the engine current as scheme policy moves.
Artificial intelligence on top
AI works alongside the rules on claims and membership analytics and insights, surfacing patterns in volume, utilisation and outcomes that rule logic alone would leave buried.
Real-time strategic recommendations
Executive management receives recommendations drawn from current claims and membership activity, rather than a report assembled at month end when the position has already moved.
Data-driven decision making
Every recommendation arrives with the activity behind it, so a decision to change a benefit, tighten an authorisation or review a provider can be justified on evidence.
Risks flagged early
Unusual claim patterns, benefit exhaustion and membership anomalies are surfaced while there is still room to respond, instead of appearing in a retrospective review.
The claim lifecycle in NEXMAS
Claim capture
Provider submissions and verified member transactions land in one intake queue with the member record attached.
Rule validation
The rules engine checks each claim against benefit limits, waiting periods and authorisations before an assessor sees it.
Adjudication
Assessors work from a single claim view, and anything outside the rules moves to a review queue instead of an inbox.
Settlement and feedback
Approved claims post for payment, and the outcome returns to the member record and to the service team.
What teams report changing
- Fewer manual handoffs between intake, assessment and payment
- One member record shared by administration and service teams
- Claim decisions that can be traced back after the fact
Integration
NEXMAS shares its member and claim records with NEXCRM, and NEXCRM comes embedded when you choose NEXMAS. NEXMAS does not depend on any other platform to run, and it is ready for integration with online biometric systems so member status, benefits and claim transactions are verified at the point of service.
See how verification and integration work
Request your NEXMAS demo
A walkthrough of NEXMAS using scenarios from your own operation, followed by the rental scope for the modules you need.