Solution
For payer claims operations, payment-integrity teams, and SIUs: every claim packet read and validated against policy, with only the genuinely ambiguous routed to humans.
The problem
When volume spikes, manual review queues grow and providers wait. Temporary staff process claims differently than the team they backfill.
Upcoding, unbundling, and duplicates surface in audits months after the money moved — when recovery is expensive and often partial.
The clinical justification for a billed code is usually in a different document than the code itself. Cross-referencing them manually is a research project per claim.
The product, not a promise
How it works
Claims arrive as EDI streams, scanned forms, or faxed records — one pipeline handles all of them.
Member data, procedure codes, and diagnoses are extracted and correlated across the whole packet.
Billed CPT and ICD-10 codes are checked against payer policy and medical-necessity guidelines.
Upcoding, unbundling, duplicates, and high-cost outliers route to nurse or SIU review with evidence attached.
Routine claims move straight through; every decision keeps its trail back to the source.
Who it's for
Claims examiner / nurse reviewer
VP of claims operations
SIU / compliance
Claims operations break when volume outruns manual adjudication. Backlogs build, improper payments leak out, and providers wait weeks for decisions. The Claims Resolution Platform is document-to-decision automation for that problem: it reads every claim packet, validates it against policy, and routes only the genuinely ambiguous ones to a human.
Claims arrive as structured EDI 837 streams, scanned HCFA and UB-04 forms, and faxed medical records — and the clinical evidence that justifies a billed code is usually in a different document than the code itself. The platform ingests all of it, extracts member data, procedure codes, and diagnosis descriptions, and correlates them across the packet, so cross-referencing clinical evidence with billing lines stops being a manual research project.
Validation runs before the money moves. Billed CPT and ICD-10 codes are checked against payer policy and medical-necessity guidelines automatically and consistently — the same rules on every claim, which is what manual review can never promise. Patterns that indicate fraud, waste, or abuse — upcoding, unbundling, duplicate submissions — are detected across claim history, not just within a single file, and flagged in real time rather than discovered in a look-back audit.
Routine, clean claims are cleared for straight-through processing. High-cost, ambiguous, or anomalous claims route to nurse or SIU review with the specific inconsistency and its source evidence already attached, so reviewers act on decision-ready information instead of re-reading the packet from scratch. Every extraction, validation, and decision links back to the exact page of the source document, and flagged decisions are human-approved. The full trail — what was read, what was checked, who decided — is preserved per claim, supporting HIPAA obligations and making audit response a query rather than a scramble. Seasonal spikes get the same rigor, without temporary adjudication staff.
Objections, answered
Every extraction and check links to the exact page of the source document, and flagged claims are decided by nurse or SIU reviewers — never by the machine. Clean claims pass on rules you configured, applied identically to every claim.
Yes — billed codes are checked against your policies and guidelines, not a generic edit set. Each validation result names the rule it applied.
Claims process inside your governed environment with access controls, and the full trail — what was read, what was checked, who decided — is preserved per claim. Audit response becomes a query, not a scramble.
The platform reads the formats you already receive — EDI 837 streams, scanned HCFA and UB-04 forms, faxed records — in one pipeline. It sits ahead of adjudication; your core claims system stays as it is.
Watch a mixed stack of 837s, scans, and faxed records get validated, flagged, and routed live in the demo.
Request a demo