AI-Powered Healthcare Claims Adjudication System
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation.
Problem Statement
The challenge addressed
Solution Architecture
AI orchestration approach
Illustrative preview (sample data, not verified outcomes): Claims selection input interface displaying test scenarios for AI-powered analysis including fraud detection, auto-pay, auto-adjust, and denial cases
Illustrative preview (sample data, not verified outcomes): Real-time AI Processing Theater showing multi-agent orchestration with active agents, processing phases, system metrics, and tool invocations
Illustrative preview (sample data, not verified outcomes): Claims processing results displaying fraud investigation recommendation with financial summary, savings breakdown by category, and processing metrics
Illustrative preview (sample data, not verified outcomes): Executive summary dashboard presenting key performance indicators including total savings, confidence score, risk assessment, and financial impact analysis
AI Agents
Specialized autonomous agents working in coordination
Orchestrator Agent
Coordinating multiple specialized AI agents requires intelligent task routing, conflict resolution, and maintaining processing state across distributed analysis components.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Manages the complete claims workflow through phase-based execution. Spawns agents based on dependencies, facilitates inter-agent message passing, builds consensus from conflicting findings, and generates comprehensive audit trails with timing metrics.
Eligibility Verification Agent
Verifying member eligibility requires checking enrollment status, coverage dates, benefit plan details, and accumulator balances across multiple data sources in real-time.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Numerical examples are scenario inputs or illustrative outputs, not validated performance results. Validates member enrollment records, confirms coverage effective dates, identifies benefit plan tier (PPO Gold, HMO, etc.), tracks deductible/out-of-pocket accumulators, and flags terminated or suspended members with 99.8% confidence scores.
Clinical Coding Validator
Healthcare claims contain complex procedure codes requiring validation against 750,000+ CCI edit combinations, MUE unit limits, and LCD/NCD coverage policies that update frequently.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Applies National Correct Coding Initiative (NCCI) bundling edits, validates modifier usage (-59, -25, -XE), enforces Medically Unlikely Edits (MUE) unit limits, and checks Local/National Coverage Determinations with real-time CMS database synchronization.
Fraud Detection Agent
Healthcare fraud costs billions annually through unbundling schemes, upcoding, phantom billing, and provider collusion. Traditional rules miss sophisticated patterns.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Numerical examples are scenario inputs or illustrative outputs, not validated performance results. Deploys Isolation Forest ML for statistical anomaly detection, calculates Z-scores against peer specialty averages, matches billing patterns against known fraud schemes, analyzes provider modifier usage rates, and generates SIU referral recommendations with 94%+ confidence.
Pricing & Benefits Engine
Claims require accurate pricing based on contracted fee schedules, UCR calculations, network discount tiers, and member cost-sharing that varies by plan and accumulator status.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Performs real-time fee schedule lookups by provider/procedure, calculates Usual Customary Reasonable (UCR) amounts, applies network discount percentages, determines member responsibility based on deductible/coinsurance/copay structures, and generates line-level payment calculations.
Medical Necessity Evaluator
Determining clinical appropriateness requires understanding diagnosis-procedure relationships, evidence-based guidelines, and payer-specific medical policies.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Leverages BioBERT NLP model for clinical context extraction, validates diagnosis-procedure clinical appropriateness, applies evidence-based treatment guidelines, checks InterQual/MCG criteria, and generates medical necessity determinations with supporting clinical rationale.
Compliance & Regulatory Agent
Healthcare claims must comply with HIPAA privacy rules, ERISA fiduciary requirements, ACA mandates, and plan-specific prior authorization rules while managing coordination of benefits.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Verifies Privacy-controlled data handling, validates ERISA fiduciary compliance for multi-employer plans, checks ACA preventive care mandates, confirms prior authorization requirements, and performs Coordination of Benefits (COB) analysis for members with multiple coverage.
Decision & Recommendation Engine
Synthesizing findings from multiple specialized agents into a coherent claim decision requires weighing conflicting signals and providing explainable rationale.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Aggregates all agent findings using ensemble weighting, resolves conflicting recommendations through confidence scoring, generates final Pay/Deny/Pend decision with line-level detail, produces explainable AI decision factors for appeals, and creates member/provider communication templates.
Worker Overview
Technical specifications, architecture, and interface preview
System Overview
Technical documentation
Tech Stack
5 technologies
Architecture Diagram
System flow visualization