AI Claims Processing
AI that reads claims, checks them against policy, and clears the clean ones while flagging the rest for review.
Claims processing is high-volume work where errors cost money and slow reimbursement. We build claims AI that extracts the data from each claim and supporting document, checks it against coverage rules and coding requirements, and clears clean claims while flagging exceptions with the reason attached. Every decision is grounded in policy and cited, so adjudicators verify quickly and denials are defensible. High-value, ambiguous, and potential-fraud cases always route to a person. The system runs inside your compliant environment with a full audit trail, owned by your team and built around your existing rules.
Extract structured data from each claim and its supporting documents, with every value traceable to the source.
Validate the claim against coverage rules, coding requirements, and policy, flagging errors and missing information.
Auto-clear clean, in-policy claims and route exceptions, high-value, and suspected-fraud cases to an adjudicator with the reasons attached.
Log every decision and override for audit, and feed reviewer outcomes back to sharpen the rules over time.
What it does
Claim extraction
Pulls structured data from claims and attachments, including scans, with each value linked to its source.
Policy validation
Checks coverage, coding, and eligibility against your rules so errors are caught before payment.
Clean-claim clearance
Auto-clears claims that pass all checks, so staff spend time only on the ones that need judgment.
Exception routing
Flags ambiguous, high-value, and suspected-fraud claims to an adjudicator with the reason and evidence ready.
Audit and compliance
Runs in your compliant environment with a full log of every decision, so denials stay defensible.
A payer auto-adjudicated 55 percent of clean claims straight through and cut average processing time by half.
Questions, answered
It auto-clears clean, in-policy claims and routes everything ambiguous, high-value, or potentially fraudulent to a human adjudicator with the evidence attached.
Yes. Every decision is grounded in your policy and cited, and the full reasoning is logged, so denials hold up under audit and appeal.
Yes. We encode your coverage, coding, and eligibility rules, so the AI enforces your policy rather than a generic standard, and your team owns it.
Bring ai claims processing to your team
Book a free consultation and we'll map the fastest path to production.