Claims Adjudication Support
Read claims and supporting documents, check them against policy, and prepare a decision for review.
What It Does
The agent reads the claim and records, checks them against policy, and prepares a recommended decision with reasons for a reviewer to confirm.Without it: Manual adjudication is slow and inconsistent, and errors drive appeals and rework.
- Checks each line against the member's plan year on the date of service
- Names the exact benefit clause behind any recommended denial
- Marks a line undecidable when a required document is missing, and names the document
- Writes the recommendation as a note on the claim, never as a status change
Illustrative example
Claim 88-2210-4 arrives with three lines: two office visits and a wheelchair charge. The agent clears the visits against the member's plan year, marks the equipment line undecidable because the prescribing note is not in document intake, and writes both findings onto the claim as a note. The adjudicator chases the prescribing note, confirms the two cleared lines, and sets the claim's status.
Claims platform
Lines awaiting decision
Benefit rules
Clauses by plan year
Eligibility system
Coverage on service date
Document intake
Prescribing notes, records
Claims adjudication support
SuggestStarts when
A claim reaches the adjudication queue with its supporting documents
How far it goes
it proposes, and a person approves before anything commits
Policy checks
Run line by line
Recommended decision
Written as a note
Reasoning trail
Clause cited per line
More Healthcare Agents
Prior-authorization drafting
Assemble prior-authorization requests against payer rules, ready for a clinician to review and submit.
Clinical-note summarization
Draft encounter summaries from the record, cited and masked, for a clinician to confirm.
Patient intake and triage
Structure intake and route cases by urgency, with governed responses and a person in the loop.
