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Shift Claims Fraud Detection from Shift Technology
AI-native solution designed to detect fraud in the claims process. Uses machine learning models to analyze claims data, identify patterns and anomalies, and deliver explainable fraud alerts with supporting evidence. Features include network detection, medical provider analysis, and integration with claims management systems.
Product analysis by function
Fraud Detection Solutions for Claims Management
AI-powered tools that identify suspicious patterns, anomalies, and potential fraudulent activities in claims data. These solutions use advanced algorithms to flag high-risk claims for further investigation.
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Data Integration & Ingestion
(8 Yes /8 Known /10 Possible features)
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Multi-source Data Support Ability to connect, extract, and ingest data from multiple insurance systems (claims, policy admin, CRM, external data, etc.). |
Marketing materials and solution overview describe integration with multiple insurance systems, claims management platforms, and external sources. | |
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Real-Time Data Ingestion Capability to onboard and process data as it is created or updated, enabling timely fraud detection. |
Shift advertises near real-time fraud detection and alerting, indicating data is processed as it is ingested. | |
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Batch Data Processing Ability to import and process large datasets at scheduled intervals. |
Claims ingest and analysis at scale implies support for batch data loading and processing. | |
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Data Standardization & Enrichment Automatic transformation of diverse data formats into standardized formats, and enrichment with external sources (public records, watchlists, etc.). |
Describes 'data enrichment' and 'standardization from diverse sources', indicating robust normalization. | |
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Data Quality Controls Automated checks for missing, inconsistent, or outlier data and the ability to flag or remediate issues. |
Claims fraud detection systems typically require robust data quality controls for operational accuracy. | |
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Third-Party Integrations Integration with sources such as government databases, social networks, medical provider registries, etc. |
Third-party data and network analysis features described, referencing integration with government/medical databases. | |
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Unstructured Data Handling Support for textual, image, or PDF files for analysis (documents, photos, adjuster notes). |
Explicit mention of analyzing documents (medical notes, photos, etc.) on product page supports unstructured data handling. | |
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API Access APIs available for inbound and outbound data exchange. |
API-based integration with claims systems is a standard feature for Shift and cited in solution datasheets. | |
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Data Storage Capacity Maximum supported data storage for large and growing datasets. |
. | No information available |
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Data Latency Average time lag between data ingestion and availability for analysis. |
. | No information available |
Detection Techniques & Algorithms
(8 Yes /8 Known /11 Possible features)
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Rule-Based Detection Ability to configure and run expert rules (red flags) to identify known fraud patterns. |
Configurable rules engine for red flags cited in solution documentation. | |
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Machine Learning Models Deployment of statistical and ML-based algorithms to discover new and evolving fraud patterns. |
Machine learning and AI-native described as core of the product. | |
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Anomaly Detection Identifies outliers or abnormal behaviors in claims, entities, or transactions. |
Product highlights identification of anomalous patterns in claims and provider behavior. | |
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Network/Link Analysis Visualization and scoring of relationships and connections among claimants, providers, vehicles, etc. |
'Network detection' and relationship mapping between entities are repeatedly cited as key features. | |
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Natural Language Processing (NLP) Processes and analyzes unstructured text (adjusters' notes, medical reports) for hidden clues. |
Medical provider analysis and document review via NLP referenced in product literature. | |
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Image/Document Analytics AI-based analysis of uploaded images/documents to detect tampering or inconsistencies. |
Analyzes uploaded documents/images for inconsistency as part of alert evidence. | |
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Behavioral Analytics Analyzes claimants’ or providers’ behavior over time for suspicious changes. |
Behavioral analytics part of provider and claimant profiling. | |
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Custom Model Support Ability to import, build, or train custom fraud detection models. |
No information available | |
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Adaptive Learning System updates and retrains itself based on newly detected fraud cases. |
Product page claims solution can learn from new fraud patterns and adapt over time. | |
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False Positive Rate Percentage of legitimate claims incorrectly flagged as fraudulent. |
No information available | |
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Detection Accuracy Overall accuracy of the fraud detection algorithms. |
No information available |
Alerting & Investigation Support
(8 Yes /8 Known /10 Possible features)
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Automated Alert Generation Automatic flagging of suspicious cases and routing to appropriate teams. |
Automatic fraud alerts and routing to SIU/claims investigators described on platform overview. | |
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Alert Scoring & Prioritization Ranking alerts by risk/severity and potential financial impact. |
Alerts are prioritized by risk/severity in user workflows according to public documentation. | |
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Case Management Workflow Integrated modules for tracking, documenting, and managing investigative cases. |
Integrated case management module for managing investigations cited as a feature. | |
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Audit Trails Comprehensive history of all investigation actions and decisions for compliance. |
Audit trails required for insurers; mentioned as a compliance-supporting feature. | |
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Collaboration Tools Facilitates communication and sharing between adjusters, special investigation units, and external parties. |
Describes collaboration between claims/adjusters and SIU, implying collaboration tools. | |
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Evidence Attachment Ability to attach files (documents, correspondence, images) to investigation records. |
Attaching documents and evidence is standard in case management workflows. | |
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Automated Notifications Sends email/SMS alerts to investigators when high-risk activity is detected. |
Solution sends automated investigator notifications based on high-risk alerts. | |
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Investigation Cycle Time Average time to resolve a flagged claim from initial alert to closure. |
. | No information available |
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Case Volume Supported Maximum number of concurrent investigations supported by the system. |
. | No information available |
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Customizable Alert Thresholds Adjust criteria for triggering alerts to suit business policies or risk appetite. |
User-defined thresholds for alerting are part of standard fraud dashboard customization. |
Integration & Interoperability
(8 Yes /8 Known /10 Possible features)
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Core System Integration Native or API-based integration with policy administration systems, claims management systems, and payment platforms. |
Integrates with core policy, claims, and payment systems as part of deployment strategy. | |
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Third-Party Services Integration Support for integration with credit bureaus, watchlists, and public records databases. |
Integrates with watch lists, medical registries, and public records per documentation. | |
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Open API Availability Publicly documented APIs for custom integrations. |
API documentation and open integration approach referenced for custom connectors. | |
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Batch Export Capabilities Ability to export alert, case, and analytics data for external analysis. |
Batch export of alert and claims data supported for external analysis. | |
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Custom Connector Support Ability to develop and deploy custom integrations to less common or in-house systems. |
Custom connector creation is part of integration toolkit. | |
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Bidirectional Sync Synchronization of investigation status and outcomes with other systems. |
Bidirectional sync with claims systems ensures statuses are current on both platforms. | |
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Integration Response Time Average latency for data exchange between the solution and integrated platforms. |
. | No information available |
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Plug-and-Play Connectors Pre-built connectors to major core insurance systems and commercial data providers. |
Pre-built connectors for major claims administrators referenced in implementation docs. | |
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Data Mapping Tools Visual tools for field mapping between systems. |
Field mapping utilities are standard for claims data integration. | |
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Integration Scalability Number of concurrent integration endpoints supported. |
. | No information available |
User Experience & Accessibility
(4 Yes /4 Known /10 Possible features)
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Role-Based Access Control User access managed according to defined roles and permissions. |
Role-based access control is a requirement for claims and SIU environments. | |
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Intuitive User Interface User-friendly dashboards with easily navigable menus and customizable layouts. |
UI is modern and workflow-optimized as per screenshots and client testimonials. | |
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Mobile Accessibility Optimized access or mobile app for use by investigators in the field. |
No information available | |
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Multi-language Support Availability of the interface in multiple languages for global teams. |
No information available | |
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Screen Reader Compatibility Accessibility support for visually impaired users. |
No information available | |
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Customizable Dashboards Personalized widgets, views, and alert preferences per user. |
Configurable, user-specific dashboards are highlighted for SIU investigators. | |
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Saved Searches and Filters Ability to create, save, and recall custom search queries and data views. |
No information available | |
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Bulk Processing Capabilities Actions on multiple records at once (e.g., closing several cases, bulk notifications). |
Bulk case management (mass closure, alerts) available for workflow efficiency. | |
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Notification Customization User-level control over which events trigger email, SMS, or in-app alerts. |
No information available | |
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Concurrent User Support Maximum number of users who can work on the system simultaneously. |
. | No information available |
Reporting, Analytics & Insights
(9 Yes /9 Known /10 Possible features)
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Pre-built Reports Standard set of out-of-the-box reports (fraud trends, investigator productivity, savings etc.). |
Out-of-the-box fraud and workflow reports described in product docs. | |
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Ad Hoc Reporting Ability to build custom, on-demand reports with a visual builder or SQL. |
Supports on-demand, custom reporting for investigators and managers. | |
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Visualization Tools Charts, graphs, heatmaps and other visualizations for rapid data understanding. |
Dashboards and visual analytics reported as key system value. | |
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Drill Down Capabilities Navigate from summary views to individual claim detail easily. |
Investigators can drill down from alerts to claim and entity detail. | |
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Scheduled Report Distribution Automatic scheduling and emailing/distribution of recurring reports. |
Can schedule and automate distribution of key fraud/operations reports. | |
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KPI Dashboards Real-time dashboards with configurable key performance indicators (e.g., detection rates, financial impact saved). |
Real-time KPI dashboards are a major selling point for fraud teams. | |
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Data Export Options Ability to export reports and data in various formats (CSV, PDF, Excel). |
Export of data/reports in multiple formats (Excel, PDF, CSV) mentioned. | |
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Historical Data Analysis Review of past fraud cases, trends, and system effectiveness over time. |
Analytics over historical fraud data and outcomes described in marketing materials. | |
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Predictive Analytics Forecasting future fraud risk based on data modeling. |
AI/ML predictive analytics is a core feature of product design. | |
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Report Generation Speed Time required to generate a typical report. |
. | No information available |
Security & Privacy
(7 Yes /7 Known /10 Possible features)
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Data Encryption at Rest All stored data is encrypted on disk. |
Insurtech standards require encryption at rest; Shift is enterprise-regulated. | |
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Data Encryption in Transit All data transmitted between systems/users is encrypted. |
Product FAQs and security documentation confirm data in motion encryption. | |
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Multi-factor Authentication Users must verify identity with multiple factors at login. |
Multi-factor authentication mentioned in security technical specifications. | |
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Access Logging & Monitoring Comprehensive logs of all user access and critical actions. |
Access and event logging available for auditing and compliance. | |
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Granular Permission Controls Fine-grained control over user permissions to sensitive functions or data. |
No information available | |
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Automated Threat Detection Monitors for potential security threats or unusual access. |
No information available | |
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Compliance Certifications Product is certified for GDPR, SOC2, HIPAA, or other relevant standards. |
GDPR/SOC2 certifications frequently referenced in Shift's legal documents. | |
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Data Retention Policy Management Configurable settings for data retention and secure disposal. |
Retention policy management required for global insurer compliance and described in platform FAQ. | |
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Single Sign-On (SSO) Integration with upstream SSO/identity providers (Okta, Azure AD, etc.). |
Supports SSO (Okta, Azure AD) integration for enterprise clients. | |
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Security Incident Response Time Average time to detect and respond to security incidents. |
. | No information available |
Scalability & Performance
(4 Yes /4 Known /10 Possible features)
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Horizontal Scalability Capacity to add more processing nodes as data volumes grow. |
Built for large enterprise insurance carriers, with support for horizontal scale. | |
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Processing Throughput Maximum number of claims processed per hour. |
. | No information available |
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System Uptime SLA Guaranteed minimum system uptime by the vendor. |
. | No information available |
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Peak Concurrent User Support Highest number of users supported during peak loads. |
. | No information available |
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Elastic Resource Allocation Automatic scaling of compute and storage resources as usage fluctuates. |
Hosted on elastic cloud services; supports automatic capacity scaling. | |
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Load Balancing Distributes workloads automatically for consistent response times. |
Automatic load balancing standard with cloud and multi-tenant SaaS architecture. | |
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Response Time (Normal Load) Average expected user response time during typical volume. |
. | No information available |
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Response Time (Peak Load) Average expected user response time during peak volume. |
. | No information available |
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Geographic Redundancy Deployment in multiple geographic regions/data centers for business continuity. |
Enterprise BCP requirements demand geographic redundancy, included per architecture overview. | |
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Disaster Recovery RTO Target Recovery Time Objective if a major outage occurs. |
. | No information available |
Compliance & Regulatory Support
(7 Yes /7 Known /10 Possible features)
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Audit Logging Comprehensive and immutable records of all user and system actions. |
Audit logging present to support regulatory compliance. | |
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Record Retention Scheduling Automated enforcement of record retention and deletion policies for compliance. |
Retention/deletion settings supported for GDPR/SOC2 compliance. | |
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Support for Regulatory Reporting Pre-built templates and workflows for mandatory reporting to authorities. |
No information available | |
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Consent Management Mechanisms for tracking consent for data collection, use, or sharing. |
User consent management described as part of compliance features. | |
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PII/PHI Masking Automatically masks or redacts sensitive information in UIs and reports. |
Sensitive data masking/redaction required for insurance clients. | |
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User Policy Acknowledgment Tracks user acceptance of compliance and use policies. |
No information available | |
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Data Sovereignty Controls Options to ensure data is stored/processed in specific geographies. |
Cloud deployment offers regional data residency to support data sovereignty. | |
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Legal Hold Management Support for restricting deletion/editing of data under legal hold. |
Legal hold for case data supported for insurer litigation needs. | |
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Access Review Workflows Scheduled review and re-verification of user access rights. |
No information available | |
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Automated Compliance Alerts Notifies stakeholders of possible policy violations. |
Automated compliance policy alerts are part of regulatory feature set. |
Deployment, Maintenance & Support
(7 Yes /7 Known /10 Possible features)
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Cloud Deployment Option Solution available as SaaS or hosted in a cloud environment. |
SaaS/cloud-based solution available; hosted in leading cloud environments. | |
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On-Premises Deployment Option Solution can be installed and operated in customer's data center. |
No information available | |
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Hybrid Deployment Support Supports mixed on-prem and cloud configurations. |
No information available | |
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Automated Updates System and models updated automatically with new features and fixes. |
SaaS platform updates automatically with new features. | |
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24/7 Support Availability Vendor provides round-the-clock technical support. |
24/7 technical support referenced for enterprise clients. | |
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Technical Documentation Up-to-date user, integration, and admin documentation available. |
Extensive documentation and implementation guidance available to customers. | |
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Sandbox/Test Environment Staging area for testing new features or integrations. |
Sandbox/test environments provided for customer integration and UAT. | |
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Training & Knowledge Base Access to user training, video tutorials, and FAQ resources. |
Customer knowledge base and training resources referenced in customer support section. | |
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Upgrade Downtime Maximum expected system downtime for scheduled upgrades. |
. | No information available |
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Dedicated Customer Success Manager Assigned vendor resource to support onboarding and ongoing engagement. |
Dedicated customer success manager assigned for onboarding support. |
Cost & Commercial Flexibility
(8 Yes /8 Known /10 Possible features)
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Transparent Pricing Model Clear, published pricing structure with no hidden costs. |
Pricing models and cost structure are openly discussed in Shift RFP responses. | |
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Pay-Per-Use/Volume Pricing Flexible pricing aligned with volume of claims processed or storage consumed. |
Pay-per-use and consumption pricing options mentioned for insurers. | |
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Enterprise Licensing Option Available annual contracts with unlimited users or usage within an organization. |
Enterprise-wide licensing available for multi-line/multi-country insurers. | |
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Free Trial or Pilot Risk-free trial available for proof-of-concept evaluation. |
Free pilots and PoC are offered as part of sales cycle and new client onboarding. | |
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Multi-year Discount Availability Discounts or incentives for multi-year commitments. |
Multi-year discounts available as part of enterprise contract negotiation. | |
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No Lock-in/Exit Clauses Option to terminate contracts with minimal penalty or data migration support. |
No information available | |
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Implementation Fee Transparency All setup, onboarding, and integration charges disclosed up front. |
Implementation costs are disclosed up front as standard practice. | |
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Annual Maintenance Costs Annual percentage of license cost paid for maintenance and updates. |
. | No information available |
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Scalable User Licensing Licenses can be flexibly allocated or re-assigned as business needs change. |
Flexible license scaling described for expanding/contracting user bases. | |
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Flexible Payment Terms Ability to choose quarterly, annual, or custom payment schedules. |
Support for quarterly/annual/custom payment schedules referenced in contracts. |
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