We claim:
1. A System for auditing insurance claims, the System comprising:
5
a source data extractor configured to extract one or more claim records from one or more sources;
a transformation engine configured to:
10 transform the one or more received claim records to a data model, wherein the
data model comprise Information present in the one or more received claim records in a pre-defmed and structured format; and load the data model to a claims audit database;
15 a segmentation engine configured to interrogate the claims audit database and categorize each claim record within the loaded data model into one or more pre-defined categories; and
a claims audit engine configured to:
20 execute one or more pre-defined audit rules corresponding to each of the one or
more categories for auditing each of the one or more claim records; and generate at least one of: audit information and one or more alerts corresponding to each of the one or more claim records based on results of the one or more executed audit rules.
25
2. The System of claim 1, wherein the one or more sources comprise claim
administration Systems employed by one or more insurance carriers, document
repositories, media repositories and third party sources.
30 3. The System of claim 1, wherein the one or more pre-defined categories are configured by one or more insurance carriers based on type of insurance, complexity of claim and typeof loss.

4. The system of claim 1, wherein the one or more audit rules are executed based on
category and stage of each of the one or more claim records.
5. The System of claim 1, wherein the claims audit engine executes the one or more
5 audit rules corresponding to one or more audit events and further wherein the one or
more audit events comprise activity audit, document audit, progress audit, engagement audit, vendor management audit and inconsistency audit.
6. The system of claim 1, wherein the generated audit Information comprise Information
10 related to one or more audit events conducted at specific stages of the claim, results of
each audit event, results of the execution of the one or more audit rules and Status of the one or more claim records.
7. The system of claim 1, wherein the one or more alerts comprise summary of the
15 results of the audit conducted by the claims audit engine for each of the one or more
claim records.
8. The system of claim 1, wherein the one or more alerts corresponding to each of the
one or more claim records are forwarded via one or more communication Channels.
20
9. The system of claim 8, wherein the one or more communication Channels comprise
electronic mails, short messaging Service, facsimile and instant messengers.
10. The system of claim 1 further comprising a user interface manager configured to
25 provide at least one: of the generated audit Information and the one or more alerts in
the form of summarized dashboards and detailed insights.
11. A computer-implemented method for auditing insurance claims, via program
Instructions stored in a memory and executed by a processor, the computer-
30 implemented method comprise:
extracting one or more claim records from one or more sources;

transforming the one or more received claim records to a data model, wherein the data model comprise Information present in the one or more received claim records in a pre-defined and structured format;
5 loading the data model to a claims audit database;
interrogating the claims audit database and categorizing each claim record within the loaded data model into one or more pre-defined categories;
10 executing one or more pre-defined audit rules corresponding to each of the one or more pre-defined categories for auditing each of the one or more claim records; and
generating at least one of: audit Information and one or more alerts corresponding to each of the one or more claim records based on results of the one or more executed 15 audit rules.
12. The computer-implemented method of claim 11, wherein the one or more sources
comprise claim administration Systems employed by one or more insurance carriers,
document repositories, media repositories and third party sources.
20
13. The computer-implemented method of claim 11, wherein the one or more pre-
defined categories are configured by one or more insurance carriers based on type of
insurance, complexity of claim and type of loss.
25 14. The computer-implemented method of claim 11, wherein the one or more audit rules are executed based on category and stage of each of the one or more claim records.
15. The computer-implemented method of claim 11, wherein the one or more audit rules are executed corresponding to one or more audit events and further wherein the 30 one or more audit events comprise activity audit, document audit, progress audit, engagement audit, vendor management audit and inconsistency audit.

16. The computer-implemented method of claim 11, wherein the audit Information
comprise Information related to one or more audit events conducted at specific stages
of the claim, results of each audit event, results of the execution of the one or more
audit rules and Status of the one or more claim records.
5
17. The computer-implemented method of claim 11, wherein the one or more alerts
comprise summary of the results of the audit for each of the one or more claim records.
18. The computer-implemented method of claim 11, wherein the one or more alerts
10 corresponding to each of the one or more claim records are forwarded via one or more
communication Channels.
19. The computer-implemented method of claim 18, wherein the one or more
communication Channels comprise electronic mails, short messaging Service (SMS),
15 facsimile and instant messengers.
20. The computer-implemented method of claim 11 further comprising providing at
least one: of the generated audit Information and the one or more generated alerts in the
form of summarized dashboards and detailed insights.
20
21. A Computer program product for auditing insurance claims, the Computer program
product comprising:
a non-transitory computer-readable medium having computer-readable program code stored thereon, the computer-readable program code comprising Instructions that when 25 executed by a processor, cause the processor to:
extract one or more claim records from one or more sources;
transform the one or more received claim records to a data model, wherein the data 30 model comprise Information present in the one or more received claim records in a pre-defmed and structured format;

load the data model to a claims audit database;
interrogate the claims audit database and categorizing each claim record within the loaded data model into one or more pre-defined categories; 5
execute one or more audit rules corresponding to each of the one or more pre-defined categories for auditing each of the one or more claim records; and
generate at least one of: audit information and one or more alerts corresponding to 10 each of the one or more claim records based on results of the one or more executed audit rules.