Insurance Claims Automation
End-to-end cashless claims lifecycle digitization: pre-authorization, enhancements, reconsiderations, final claims, and batch settlement reconciliation with line-by-line auto-mapping.
Why it matters
The cashless claims journey is long, document-heavy, and full of places to leak value — pre-authorization, mid-treatment enhancements, reconsiderations on rejections, final claim submission, and reconciling what the insurer settled against what the hospital billed. Handled by hand across email and spreadsheets, mismatches surface late and disallowances go uncontested. We digitize the entire lifecycle in one system, with AI reading insurer letters at source and a pipeline that learns from every disallowance.
What We Do
Problem Addressed
The cashless claims lifecycle is document-heavy and manual, so mismatches surface late and disallowances go uncontested.
Where It Fits
The claims-automation layer spanning pre-auth to settlement across your payer relationships.
Key Capabilities
Generate pre-auth from HIMS
Patient and diagnosis details are pulled from HIMS, ICD-10 coded, and a pre-auth is generated ready for signature — no manual data entry.
Verify before submission
Cash components are checked against the policy and Tariff MOU up front, catching mismatches before they become disputes.
Categorise every response
Payer responses are auto-captured and classified — Approved, Partial, Denied, Docs Required — and routed to the desk for action.
Reconcile and appeal
Settlements are mapped line by line; where a disallowance is appealable, the appeal letter is generated automatically.
Learn on the next claim
Disallowance reasons feed back into pre-auth, so the same mistake is corrected before it recurs.
The claims lifecycle is a sequence of specialised, high-volume decisions — ideal for orchestrated agents. Extraction, verification, reconciliation, and appeal-drafting agents run under explicit control flow, stay model-agnostic, and keep a full audit trail for every action.
Extraction & categorisation
Reads insurer letters and classifies each response so nothing needing action sits unnoticed in an inbox.
Reconciliation & appeal
Maps settlements line by line and drafts appeal letters for appealable disallowances automatically.
Model-agnostic
Routes to the best model per task and can run inside your infrastructure for data governance.
Feedback loop
Disallowance reasons feed back into pre-auth so the pipeline improves claim over claim.
How Clients Engage
Assess
Evaluate current workflows and identify where the platform delivers the most value.
Design
Architect a standards-based solution tailored to your clinical or academic reality.
Implement
Build and integrate with production systems, with humans in the loop where it matters.
Scale
Harden, monitor, and expand across teams, sites, or the full student base.
Insights & Resources
Transform Your Healthcare Operations
Partner with us to ship production-grade healthcare platforms that run in live clinical and revenue environments.
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