Smarter Claims. Lower Costs.

Claims are received through multiple channels — EDI, portal upload, direct provider submission, and member reimbursement requests. Every claim is logged, acknowledged, and assigned a unique reference on receipt.

Each line item on a claim is reviewed individually — verifying that services billed were covered, authorised, and appropriately priced. Line-level decisions are documented and auditable.

Our system validates CPT codes against standard coding guidelines, checking for unbundling, upcoding, and modifier misuse — ensuring that billed procedures reflect the care actually delivered.

Diagnosis codes are validated for accuracy, specificity, and consistency with the billed procedures. Mismatches between diagnosis and treatment are flagged for clinical review.

Our system automatically identifies duplicate submissions — same provider, same member, same date of service, same procedure — preventing double payment across all claim channels.

Claims for high-cost procedures, extended admissions, and specialist services are reviewed against evidence-based clinical criteria to confirm that the care was medically necessary and appropriate.

Every claim is adjudicated against the member's specific benefit plan — applying deductibles, co-pays, co-insurance, sub-limits, and exclusions accurately and consistently.

Billed charges are compared against our medical pricing database and contracted rates. Overpriced claims are identified and negotiated before payment — protecting the insurer's cost base.

Automated and manual fraud detection identifies unusual billing patterns, phantom services, provider collusion, and member misrepresentation — with escalation protocols for confirmed cases.

Members, providers, and clients can track the status of any claim in real time — from receipt through adjudication to payment — via our portal and reporting tools.

Clear, detailed Explanation of Benefits documents are issued to members and providers for every adjudicated claim — showing what was billed, what was covered, and what was paid.

Approved claims are batched and processed for payment on defined schedules — with remittance advice issued to providers and reconciliation reports delivered to clients.