AI for Healthcare
Medclaims Intelligence
An AI-native medical claims agent that ingests claims in any format, adjudicates against benefit and coding rules, flags fraud, waste and abuse, and drives clean payment, turning a manual, error-prone back office into a straight-through process.
- Ingest claims from EDI 837, portals, PDFs and fax, auto-extracted and validated
- Rules-driven adjudication against eligibility, benefits, ICD/CPT coding and pricing
- Fraud, waste & abuse detection, duplicates, upcoding and anomaly flags
- Auto-generated denial reasons, appeal letters and 835 remittance
Any
Claim Format
STP
Straight-Through
HIPAA
Compliant
Platform Overview
Six modules, one claims lifecycle
From first-notice intake to remittance, every step of the claim runs on the same adjudication data and audit trail.
Intake & Digitization
Any format · Clean data
Capture
- EDI 837, portal, PDF & fax ingestion
- OCR & structured extraction
- Field-level validation & scrubbing
- Member & provider matching
Adjudication Engine
Eligibility · Benefits · Coding
Auto-Adjudicate
- Eligibility & coverage verification
- Benefit & plan-rule application
- ICD / CPT / HCPCS code validation
- Contracted-rate & fee-schedule pricing
Fraud, Waste & Abuse
Detect before you pay
Integrity
- Duplicate & split-claim detection
- Upcoding & unbundling flags
- Outlier & anomaly scoring
- Provider pattern analysis
Denials & Appeals
Fewer denials · Faster appeals
Resolve
- Standardized denial reason coding
- Auto-generated appeal letters
- Resubmission & correction workflow
- Root-cause denial analytics
Payment & Remittance
EOB · ERA · Posting
Pay
- EOB & 835 ERA generation
- Payment posting & reconciliation
- Coordination of benefits (COB)
- Provider & member statements
Analytics & Compliance
Turnaround · Audit · Trust
Govern
- Turnaround-time & auto-adjudication KPIs
- Denial-rate & recovery dashboards
- Full HIPAA-grade audit trail
- Every AI decision logged & explainable
Straight-through claims, without the leakage
Manual adjudication is slow, costly and inconsistent. Connecting intake, rules, integrity and payment in one agent makes claims fast, accurate and auditable.
Faster Adjudication
Straight-through processing clears clean claims in seconds and routes only true exceptions to humans.
- Seconds, not days
- Exception-only review
- Lower backlog
Fewer Errors & Denials
Rule- and code-validated adjudication cuts avoidable denials and costly rework at the source.
- Code-validated
- Fewer reworks
- Lower denial rate
Less Fraud & Leakage
FWA detection stops duplicate, upcoded and anomalous claims before payment goes out the door.
- Pre-payment flags
- Duplicate defense
- Recovery insight
Audit-Ready Compliance
Every decision is logged, explainable and HIPAA-aligned, so the system scales without compliance risk.
- HIPAA-aligned
- Explainable AI
- Full audit trail
Connected AI. Built to Scale
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