⚙ Platform Deep Dive

7 AI Modules.
One Intelligence Layer.

Deploy individually or as a full platform. Each module is Egypt-native, FRA-compliant, and delivers measurable ROI from day one — with zero upfront cost in the pilot.

7
AI Modules
25–40
Fraud Archetypes
94.2%
Detection Accuracy
<5s
Claim Decision
MODULE 01Egypt-native AI

Fraud Detection AI

Real-time AI scoring on every claim using 25–40 Egypt-specific fraud archetypes. The only system trained on Egyptian claims data, ICD/CPT codes, local pharmacy patterns, and FRA-defined fraud categories.

How it works
1
Claim submitted — hospital or pharmacy sends claim via API in real time
2
AI scores simultaneously against all 25–40 archetypes within 4.3 seconds
3
Decision assigned: Auto-approve (<30) · CMO review (30–70) · Auto-reject (>70)
4
CMO reviews flagged claims with full AI reasoning and archetype evidence
5
FRA audit trail auto-generated for every decision — 100% regulatory compliant
94.2%
Detection accuracy
4.3s
Avg. scoring time
25–40%
Fraud recovery rate
100%
FRA audit coverage
🔍 Fraud Analysis — Claim #IRH-4821 ⚠ HIGH RISK
Provider
Cairo Medical Centre
Amount
EGP 3,200
Type
Pharmacy
87
Fraud Risk Score (out of 100)
🔴 Phantom Prescription82% match
🔴 Unictam Counterfeit71% match
🟡 Brand Upcoding44% match
✓ Approve
⚐ CMO Review
✗ Reject
🧠 Insurance Health Score High Risk
SM
Sara Mahmoud
IRH-2026-00101 · Class A
742
Health Risk Score (0 = best · 1000 = critical)
Primary Risk Factors
Type 2 Diabetes Medication Non-Adherence High ER Frequency Hypertension
→ Enroll in Preventive Care Program
MODULE 02Predictive underwriting

Insurance Health Score

A continuous, ML-driven risk score per member — updated after every claim, pharmacy interaction, and clinical event. Enables dynamic underwriting, case management triggers, and proactive intervention before costs occur.

How it works
1
Multi-source data ingestion: claims history, pharmacy, demographics, chronic disease markers
2
ML model scores each member on a 0–1000 scale, updated continuously after every interaction
3
Segments assigned: Green (0–300) · Amber (301–600) · Red (601–800) · Critical (801–1000)
4
Insurer action: adjust premium, trigger care management, flag for preventive protocol
30–60
Day prediction horizon
Real-time
Score updates
5×
Risk stratification depth
1.2M
Members scored
MODULE 03Pre-loss intervention

AI Claim Predictor

Forecasts high-cost claims 30–60 days before they occur — giving insurers and TPAs advance notice to intervene with preventive protocols, care management, and budget provisioning before a costly event happens.

How it works
1
Signal monitoring: tracks pharmacy refill patterns, specialist visit frequency, ER usage trends
2
Pattern recognition: identifies deteriorating chronic disease markers and care-seeking escalation
3
High-cost claim predicted with estimated cost range 30–60 days in advance
4
Insurer activates: care coordinator outreach, preventive protocol, and budget reserve
30–60
Day advance warning
40%
Fewer preventable admissions
EGP 15K+
Avg. cost averted per event
87%
Prediction precision
📊 High-Cost Claim Predictions 3 Flagged
Members predicted to submit high-cost claims within 60 days
Ahmed Hassan — IRH-2026-00204
Cardiac event risk · EGP 45,000–80,000 predicted
14 days
Fatma Ibrahim — IRH-2026-00389
Diabetes complication · EGP 18,000–35,000 predicted
28 days
Mohamed Ali — IRH-2026-00512
Renal deterioration · EGP 12,000–22,000 predicted
45 days
Nour Khalid — IRH-2026-00601
Low risk · Stable · No intervention needed
Clear
🏥 Hospital Routing — Orthopedic Referral 3 Options
Ranked by Value Score (cost + quality + availability)
1
Cleopatra Hospital — Heliopolis
Quality: 9.1/10 · 4.2km · Pre-auth: Ready
EGP 8,200
↓ 28% below avg.
2
As-Salam International
Quality: 8.8/10 · 7.1km · Pre-auth: 2h
EGP 9,600
↓ 17% below avg.
3
Cairo Medical Centre
Quality: 8.4/10 · 2.8km · Pre-auth: 4h
EGP 11,400
Near avg. cost
→ Send Pre-Auth to Cleopatra Hospital
MODULE 04Network optimization

Auto Hospital Routing

Intelligently routes patients to the most cost-effective, clinically appropriate provider in real time. Combines quality scores, network pricing benchmarks, and patient proximity to deliver the best value per claim.

How it works
1
Referral request received — doctor or member requests admission or specialist
2
Platform queries network for available providers, quality scores, pricing vs. benchmarks
3
Top 3 ranked by Value Score: clinical quality + cost + proximity + bed availability
4
Pre-authorization triggered automatically to selected provider — approved in <4 hours
20–35%
Per-claim cost reduction
<4h
Pre-authorization time
340+
Network providers
9.1
Avg. quality score / 10
MODULE 05Chronic disease management

Preventive Care Program

Proactive chronic disease management and early intervention for high-risk members — reducing preventable hospitalizations by up to 40% across the insured pool. Care coordinators are supported by AI-generated protocol recommendations.

How it works
1
High-risk members identified via Health Score module (score >600)
2
Care coordinator assigned — AI recommends condition-specific protocol (Diabetes · Cardiac · Renal · Hypertension)
3
Member enrolled in program via patient app — reminders, screenings, medication adherence tracking
4
Outcomes tracked against baseline — insurer sees hospitalizations avoided and cost impact in real time
40%
Fewer preventable admissions
5
Chronic conditions managed
EGP 22K
Avg. hospitalization cost avoided
Patient app
iOS + Android
❤️ Care Plan — Sara Mahmoud Type 2 Diabetes
SM
Care Coordinator: Dr. Amr Farouk
Protocol: Diabetes Intensive Management
Active Care Steps
💊
Daily medication adherence check via app
✓ Done
🩺
Monthly HbA1c blood test at Alpha Labs
✓ Done
👁️
Quarterly ophthalmology screening
Scheduled
🥗
Nutrition counseling — 2 sessions booked
Pending
📊
Endocrinologist review — 6-month
Upcoming
↓ Predicted hospital admission risk reduced by 38% since enrollment
💰 Premium Adjustment — Renewal 2027 −18% Discount Earned
YM
Youssef Mostafa · Health Points: 1,820
Annual renewal · Class B Premium
Behavioral Discount Breakdown
✓ Annual health check completed−5%
✓ Medication adherence >90%−3%
✓ Preventive screening × 2−6%
✓ BMI improvement (−3 points)−4%
Base premium (Class B)EGP 14,400 / yr
Your 2027 Premium
EGP 11,808 / yr
MODULE 06First in Egypt

Dynamic Premiums

Members earn lower premiums through verified healthy behaviors — the first behavior-linked premium system in Egypt's private health insurance market. Insurers gain a healthier risk pool, higher engagement, and a powerful retention tool.

How it works
1
Insurer sets incentive rules: which behaviors earn points and what discounts they unlock at renewal
2
Member tracks behaviors via patient app: check-ups, medication adherence, screenings, lifestyle
3
Health Points accumulated throughout the policy year with verified evidence per action
4
Premium adjusted at renewal — up to 25% discount for highest-performing members
−25%
Max premium discount
5+
Tracked healthy behaviors
First
In Egypt's insurance market
↑ 34%
Member retention improvement
MODULE 07Single source of truth

Golden Insurance Dashboard

Real-time intelligence across all 8 ecosystem parties in a single command center. Every insurer, TPA, and hospital CFO gets their own role-specific view — from executive KPIs to claims operations to FRA regulatory reporting, all auto-generated.

How it works
1
Real-time data aggregation from all 8 connected parties — hospitals, insurers, pharmacies, labs
2
Role-based views: Executive · Claims Ops · Risk Management · Compliance · Pharmacy
3
Anomaly alerts triggered for fraud spikes, cost overruns, and compliance gaps
4
FRA reports auto-generated — monthly, quarterly, and annual — with full CMO sign-off trail
8
Ecosystem parties connected
Real-time
Data refresh rate
Auto
FRA report generation
5
Role-based dashboard views
📈 Executive Dashboard — GlobeMed TPA ● Live
EGP 2.4M
Fraud recovered MTD
−15.3%
Loss ratio improvement
1,247
Claims today
87%
Auto-approved
Fraud Recovery Trend (Jan–May)
JanFebMarAprMay ↑
📄 FRA Report
↓ Export CSV
End-to-end journey

How a Claim Flows
Through the Platform

From patient presentation to payment — every step automated, audited, and FRA-compliant.

🪪
QR Verification
Member scans digital health card at provider. Eligibility verified in <1 second.
⚡ <1 second
🔍
AI Fraud Scoring
Claim scored against 25–40 archetypes. Confidence score assigned instantly.
⚡ 4.3 seconds
⚖️
Decision Layer
Clean claims auto-approved. Flagged claims routed to CMO review queue.
🕐 <4 hours
✅
Payment + Audit
Payment processed. FRA audit trail auto-generated. Dashboard updated.
⚡ Automated
✓ 87% of claims fully automated ✓ 100% FRA audit trail ✓ Zero paper. Zero manual entry.
Built for Production

Technical Architecture
& Compliance

Enterprise-grade infrastructure designed for Egypt's regulatory environment. API-first, PDPL-compliant, and built to integrate with existing insurer and TPA stacks in under 4 weeks.

Technical Stack
🔌
API-First Architecture
REST APIs with webhooks and real-time event streaming. Pre-built connectors for GlobeMed, Bupa Egypt, and AXA One Health. Custom integration support for all Egyptian insurers.
🔒
Security & Encryption
AES-256 encryption at rest and in transit. JWT authentication, role-based access control (RBAC), and multi-factor authentication for all admin users.
☁️
Cloud Infrastructure
Cloud-hosted with 99.9% uptime SLA. Auto-scaling to handle peak claims periods (Ramadan, major hospital events). Full data residency in Egypt.
📱
Patient App
Flutter-based iOS and Android app. White-labelled for each insurer. QR verification, claims tracking, benefit navigation, and appointment booking.
Compliance & Regulation
⚖️
FRA-Compliant
All AI-driven insurance decisions operate within Financial Regulatory Authority compliance guidelines
Active
🔐
PDPL 151/2020
Full compliance with Egypt's Personal Data Protection Law — data localization, consent management
Active
🩺
CMO Oversight
Licensed Chief Medical Officer (Egyptian Medical Syndicate) reviews all AI-flagged decisions
Active
📋
ICD / CPT Coding
All AI models trained on Egyptian-approved ICD-10 and CPT coding standards
Active
🏆
ISO 27001
Information security management certification in progress for Series A milestone
In Progress
🌍
NPHIES Ready
Saudi Arabia's national health exchange protocol — ready for KSA MENA expansion
MENA Phase
Zero Risk · 90-Day Pilot

See the Platform
In Your Environment

Deploy Fraud Detection AI in a 90-day pilot — we earn only on validated recoveries. No upfront cost, no platform fee, full FRA compliance from day one.

Request a Demo → Investor Deck
94.2% Detection Accuracy · <5s Claim Decision · 25–40% Fraud Recovery · FRA Compliant · PDPL 151/2020