Secure clinical data exchange and audit compliance
Healthcare business rules engine
Automate healthcare decisioning, from eligibility to claims.
Keep pace with changing regulations, cut administrative overhead, and streamline clinical workflows. Your team updates the business rules in minutes, your systems call them over REST.
SOC 2
ISO 27001
HIPAA-ready audit trail
CUSTOMERS
Healthcare organizations already running on DecisionRules
G2 high performer
AWS & Azure marketplace
Cancer screening logic and incidental finding tracking
State-level medical assistance eligibility rules
Pharmacy discount and promotion management
Use cases
Streamline healthcare rules or build entirely new ones
For Payers, TPAs & Health Plans
A Plan Sponsor changes a benefit. It sits in a PDF your claims system never sees. You pay claims you shouldn't, then chase the money. Every day.
From minutes to milliseconds. Eligibility checks via API instead of manual lookup.
Stop wrongful payments before they leave. Pre-adjudication catches mismatches in real time.
Plan Managers update rules directly. No IT ticket. No deployment cycle. No waiting.
Full audit trail for ERISA compliance. See which rule fired and why.
AI Assistant
AI that helps you build the rules, not make the call
In healthcare, every decision has to be deterministic, repeatable, and auditable. So the AI Assistant works where it is safe to: drafting, explaining, and testing the rules your team owns. The live decision always runs on deterministic logic you can audit, line by line.
AI rule building. Measured, not hyped.
Healthcare organizations run on thousands of rules that change constantly. Payer contracts renegotiate. CMS guidelines update. Clinical evidence evolves. But those rules still live in places that can't keep up.
The AI Assistant never makes the clinical or coverage decision. It accelerates the people who build and review the rules.
Draft Eligibility and Claims Rules
Describe a coverage rule in plain language and the AI Assistant drafts the Decision Table and generates test data across edge scenarios.
Co-author Clinical Pathway Logic
The AI Assistant helps author dosage, allergy, and renal-adjustment logic and explains the rationale behind every branch, so clinical reviewers can sign off with confidence.
Structure Trial Elegibility from any Protocol
Turn a 200-page protocol into structured inclusion and exclusion rules in a fraction of the time.
Security
AI that meets your compliance requirements
SOC 2 & ISO 27001
Audited and certified. Enterprise-grade security you can verify.
No public training
Your rules and data are never used to train AI models.
Data residency
US, EU, or on-premise. You choose where your data lives.
SSO & access control
Corporate identity provider integration. Full RBAC.
The Challenge
Your rules are trapped. Your teams are paying the price.
Healthcare organizations run on thousands of rules that change constantly. Payer contracts renegotiate. CMS guidelines update. Clinical evidence evolves. But those rules still live in places that can't keep up.
Legacy
code
Eligibility and grouping logic buried in stored procedures only two developers understand. Every "small change" becomes a sprint item.
Spreadsheet
drift
Benefit rules in Excel files, emailed between departments. Nobody's sure which version is current.
PDF
purgatory
Plan documents, clinical protocols, and fee schedules sitting in static PDFs that can't talk to your systems.
Tribal
knowledge
Key rules live in people's heads. When they're on vacation, or leave, the knowledge goes with them.
Automatization
15min
Average manual eligibility check per claim, replaced by sub-100ms API calls
Information sourceRevenues
3-5%
Revenue lost by providers due to contract calculation errors and underpayments
Information sourceCosts
$600K-8M
Daily cost of clinical trial delays caused by manual screening processes.
Information sourceThe platform
One platform for every rule in your organization
DecisionRules gives both your business teams and developers the tools they actually need. Visual rule builders for the people who own the logic. A clean API for the people who build the systems.
Decision Table
Define eligibility, coverage, and pricing logic in a clear, spreadsheet-like format your team can read and update.
Decision Tree
Branching IF-THEN logic for structured, visual decisions like triage or tiered approvals.
Decision Flow
Combine multiple rules and scripts into one visual workflow, managed through APIs.
Scripting Rule
Custom JavaScript for advanced calculations like dosage by weight or renal adjustment, while business data stays in tables.
Lookup Table
Centralized dictionaries for code sets and fee schedules, retrieved by key (for example ICD/CPT codes or plan IDs).
AI Assistant
Build, explain, and test rules faster. Around 60% faster authoring, validated internally.
Auditing
Capture every decision with timestamps and filter by Rule ID or correlation ID for audit-ready compliance.
Access Management
Roles, custom permissions, and single sign-on so business and IT collaborate securely.
Ready-to-use templates
Start from a template, not from scratch
Prebuilt templates you can clone, adapt to your own contracts and protocols, and call over REST.
healthcare insurance featured
Compensation Claim Automation
Automate the end-to-end handling of workers' compensation claims using AI-powered medical report analysis — extract the clinical data you need and drive every downstream decision automatically.
healthcare
Clinical Trial Eligibility Engine
This Decision Flow consumes a RESTful API call from your Electronic Health Record (EHR) or Clinical Trial Management System (CTMS) to determine if a patient meets the foundational and study-specific criteria for enrollment.
healthcare
Healthcare Insurance Claim Eligibility Engine
This Decision Flow consumes a RESTful API call from your core claim system to determine whether a client has active healthcare plan coverage and if any specific exclusions apply to the services rendered.
What if your rules weren't trapped in spreadsheets and code?
Book a 30-minute demo for your healthcare use case. See eligibility, clinical pathways, and claims run inside DecisionRules.
No credit card required. All features unlocked. Your first rule in under 5 minutes.
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