Move every health claim from intake to decision with less drag.
InsureAI keeps every required review layer distinct while turning IPD and OPD claims into policy-backed, audit-ready outcomes.
5
Independent review layers
4
Outcome types prepared
1
Evidence trail retained
CLM-24891
Ready for adjudication
Recommended payable
Rs 82,460
Suggested deduction
Rs 11,240
The adjudication journey
The claim does not just get processed. It gets resolved.
The scroll path keeps the required sequence explicit. The cards beside it show what changes for the reviewer at each point.
Scroll path
Billing
Bills, line items, NME
Tariff
SOC, packages, rates
Adjudication
Policy, benefits, limits
FWA
Fraud, waste, abuse
Audit
Reasons, notes, trail
Inputs
Documents become line items reviewers can trust.
Bills, invoices, consumables, procedures, room rent, and supporting documents are parsed into structured charge lines before any payout view is prepared.
Bill review complete
Rate context
The billed amount is compared before policy logic starts.
Hospital tariff, SOC limits, package rules, contracted rates, and rate mismatches are reviewed as their own step instead of being buried inside billing.
Tariff exceptions isolated
Policy position
Eligibility and benefits shape the payable recommendation.
Policy benefits, exclusions, limits, waiting periods, clinical context, and eligible deductions are applied to prepare the claim outcome.
Policy outcome prepared
Exception lane
Risk signals are isolated before payout.
Suspicious patterns, inflated charges, duplicates, and review-worthy anomalies move into an exception lane instead of slowing every claim.
Exceptions isolated
Decision record
The final outcome carries its reasons forward.
Pay, deduct, flag, or reject outcomes are packaged with clear notes so reviewers can defend the decision and improve the next one.
Audit trail ready
What gets measured
Every claim is checked against the inputs that actually decide the outcome.
Inputs
Documents converted into claim context
Bills, policy details, hospital data, and clinical records are arranged before review starts.
Rules
Tariff and policy logic applied clearly
Rate checks, benefit limits, exclusions, and eligibility are surfaced without mixing the steps together.
Exceptions
Review risk separated from routine work
Suspicious charges, duplicates, inflated billing, and manual-review triggers move into a focused lane.
Evidence
Reasons carried into the final packet
The amount, adjustment, exception, policy basis, and reviewer note stay attached to the outcome.
What comes out
A cleaner packet for the reviewer.
Once the path is clear, the interface stays focused on what the team can act on: structured charges, rate variance, policy basis, exception context, and the final record.
See it on your claimsStructured bill view
Turns line-item noise into a clear view of payable charges, non-payable items, and deductions.
Rate variance summary
Highlights where billed rates diverge from hospital tariff, SOC, package, and contracted-rate rules.
Policy basis
Connects benefits, policy limits, clinical context, and deductions into a review-ready payout outcome.
Exception brief
Pulls suspicious patterns and inflated charges forward so teams can focus attention where it matters.
Decision record
Keeps the reason, evidence, and reviewer trail attached to the payout outcome.
Audit-ready outcome
Every decision needs a clear reason.
By the time a claim reaches the end of the page, the same thing should be true in production: the amount, the deduction, the flag, and the reason are all visible together.
01
Hospital tariff validation
02
SOC and package checks
03
Policy benefit validation
04
NME detection
05
Deduction adjustments
06
Medical scrutiny
07
FWA flagging
08
Audit-ready decision notes
Final CTA
Give every claim a cleaner path to resolution.
Move high-volume claims through a cleaner review path with less manual drag and a clearer reason behind every payout.
See the DemoBuilt for
TPAs, insurers, and high-volume claim teams.