Claims Auto Adjudication is a cutting-edge solution designed to streamline complex manual adjudication tasks by automating scheduled and ad-hoc processes with unmatched efficiency and precision. It handles bulk claim processing, eligibility verification, reprocessing, repricing, and denial management while seamlessly integrating with existing systems. By minimizing manual effort, it improves accuracy, accelerates claim resolution, and ensures compliance with payer policies—optimizing the revenue cycle.
1M+
CLAIMS PER MONTH
400
CLAIMS PER MINUTE
800 Claim Lines/min
100%
ACCURACY
< 5%
REWORK RATE
99.9%
UPTIME
Why Choose Our Claims Auto Adjudication?
Speed
Processes 400 claims and 800 claim lines per minute, minimizing manual effort and maximizing efficiency. Unlike traditional RPA, our claims adjudication engine ensures accuracy, compliance, and seamless system integration.
Accuracy
Ensure 100% accuracy in processing claims, applying business rules with consistent precision.
Cost-Effective
​Lower operational costs with increased automation, driving immediate ROI by reducing manual interventions and processing time.
Advantage
Due to its high-speed processing, our application doesn’t need to run 24/7 and overload systems. Instead, claims can be adjudicated on a scheduled basis, ensuring smooth operations without affecting production systems during work hours.
KEY CAPABILITIES
High-speed Bulk Processing
Scheduled or on-demand bulk adjudication.
Seamless Integrations
Connectors for eligibility, grouper/pricing, and virtual examiners.
Complete Auditability
Automated audit trails for full transparency.
Flexible Scheduling
Daily automation or manual triggers across DBs.
Reprice & Reprocess
Fast reprocessing of paid/open claims for corrections and fee schedule updates.
Resilient Execution
Script sequencing, automatic recovery, and zero re-runs.
Rule Library
Includes rules for Eligibility Denials, Duplicates, Authorization Matching, Bundled Services, Non-Covered Services, and more. Rules live in structured database tables for easy customization and help improve first-pass resolution by 40%.
Third Party Integration
Ability™ (eligibility) · Microdyne™ · 3M Grouper™ (DRG, APC, APR-DRG) · PCG Virtual Examiner™ — connectors available for both real-time and batch edits.
Reprice & Reprocess Claims Efficiently
Automatically reprocess paid claims and reprice open claims to correct overpayments, underpayments, and fee schedule adjustments. Fully compliant with contract-specific pricing rules to ensure consistent, audit-ready reimbursement.
Reliable, Resilient, and Resource-Efficient Execution
Enterprise-grade stability with script sequencing, auto-recovery from timeouts/reboots, and scheduled batch execution that avoids 24/7 runs eliminating unnecessary production load and preventing re-runs.
Key Features
Authorization Management
The solution automates the approval of authorizations, ensuring that medical services meet payer guidelines before treatment. It focuses on verifying and granting authorizations, not on processing or paying claims based on approvals.
Reprocess Claims Efficiently
Automatically reprocess paid claims to correct overpayments, underpayments, and fee schedule adjustments with unparalleled speed and accuracy. The system ensures compliance with the latest regulations and payer policies while minimizing revenue leakage.
Repricing Claims
Seamlessly reprice claims based on updated fee schedules, contract terms, and regulatory changes. The system ensures accurate reimbursement by applying the latest payer-specific pricing rules, provider contract rates, and negotiated payment structures.
Handling Denied Claims
Identify and correct denied claims related to medical necessity, bundling/unbundling, coordination of benefits (COB), and prior authorization issues. Automate the reprocessing of denials, apply rule-based corrections, and resubmit claims efficiently to maximize reimbursements.
Auditability
The solution provides complete transparency with automated audit trails that track every action taken during the claims process. This ensures full accountability, making it easier to monitor, review, and verify the integrity of each claim at any stage.
Regulatory Compliance
Designed to meet the latest industry standards and payer guidelines, the solution ensures all claims are processed in full compliance with relevant regulations. Regular compliance checks help mitigate risks and ensure adherence to evolving regulatory requirements, simplifying audits and reducing the potential for errors.
Claims Auto Adjudication Workflow
List of Claims
Review and categorize claims that require reprocessing, repricing, or denial due to errors, policy updates, or discrepancies.
Submit Claims
Upload accurate claim details into the system, ensuring all required information and supporting documents are included for smooth processing.
Process Claims
Choose between immediate or scheduled processing based on priority, claim type, and business requirements to optimize workflow efficiency.
Monitor Progress
Track progress in real-time, identify delays, detect potential errors, and ensure timely resolutions to prevent processing bottlenecks.
Review Results
Verify processed claims, assess accuracy, and generate detailed reports for audits, compliance, and performance analysis.
