Service Oriented Fuzzy Decision Model for Health Insurance Claim

Insurance claim is a fascinating issue to study. A potential loss for the insurance company is major coming from this issue. Thus, many studies performed already to answer such an issue. This study takes aim to develop a computational decision model based on service technology. Four fundamental methods operated in constructing the model and its implementation in service technology. The analytical hierarchical process (AHP) and fuzzy logic methods are two methods benefited to construct the model; where the AHP used to prioritize thirteen parameters considered and the fuzzy logic with its inference capability operated to generate the decision. Object oriented is an analysis and design method to analyze and design the model implanting it in service oriented architecture (SOA). Then, SOA conception functioned to deploy the model in the service architecture. Ultimately, the suggested framework comprising three layers of service-oriented architecture (SOA), namely business process, service interface, and application, has been established, alongside the integration of eight essential services that connect these three applications. The model demonstrates simulation outcomes indicating that 31.47% of claims are categorized as low risk and have been approved, 17.64% of claims are considered moderate risk with currently pending decision status (requiring additional investigation), while 50.89% of claims are classified as high risk with also pending decision status.