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Third-party administrators
TPAs that administer self-funded plans and need rules per client plan design.
Healthcare / Claims Adjudication
Claim adjudication software development for payers and TPAs
Claims that pend for data a system could have checked at intake cost health plans and TPAs examiner time and provider goodwill. Agnotic Technologies builds claims adjudication systems that take in X12 837 claims, run edits and benefit and pricing rules, auto-adjudicate clean claims and route the rest to pend queues with a reason.
837 · 835
Claims in, remittance out, as HIPAA standard transactions
Edits first
Validation at intake, before a claim can pend
Pend reasons
Every pended claim carries a reason and an owner
Trusted by global innovators
Industry Overview
What is claim adjudication software?
Claim adjudication software is the system a health plan or TPA uses to receive X12 837 claims, validate them, apply benefit and pricing rules, decide what to pay and return an 835 remittance. Agnotic Technologies builds claims adjudication systems for payers and TPAs, with auto-adjudication for clean claims and reasoned pend queues for everything else.
Industry Challenges
Where do adjudication systems lose claims?
Most adjudication problems are not pricing errors. They are claims that stop moving.
Edits that run late: a claim passes intake, then fails a code set or provider check that could have run on arrival.
Pends without a reason: examiners open a claim to find out why it stopped, which turns a queue into a backlog.
Rules nobody can read: benefit and pricing logic buried in code or spreadsheets, so every change waits for a developer.
Remittance mismatches: 835 files that do not reconcile to the decisions the system made, which triggers provider calls and appeals.
Our Approach
How do auto-adjudication and pend queues work together?
Auto-adjudication pays or denies claims that meet every rule without a person touching them. Pend queues hold the rest with a reason, an owner and a deadline.
Rules as data
Edits, benefit rules and pricing schedules are configuration your analysts maintain, versioned and testable, not code.
Decide or pend, never stall
Every claim either reaches a decision or lands in a named queue with a pend reason and the data needed to clear it.
Examiner workbench
One screen with the claim, the rule that fired, the member's benefits and the provider's contract, with an audit trail of every change.
Appeals linked to the decision
An appeal opens against the original adjudication record, so reviewers see what was decided and why.
Capabilities
What do we build in a claims adjudication system?
Modules we build for payers and TPAs, on their own or as part of a core administration system.
837 claim intake
Professional, institutional and dental 837 files from clearinghouses and portals, acknowledged with 999 and 277CA.
Edits and validation
Code set, provider, member and duplicate checks run at intake, each with a configurable action: reject, pend or warn.
Benefit configuration
Plan designs, accumulators, cost sharing and coverage rules applied per member and date of service.
Pricing engine
Fee schedules, contract terms and reference pricing applied to each line, with the pricing source recorded.
Pend queue management
Queues by reason, routing to the right team, aging and deadlines, and bulk resolution when a rule or a record changes.
835 remittance and appeals
Remittance files and explanations of payment generated from the decision, plus an appeals workflow tied to it.
How It Works
How does a claim move through adjudication?
The decision flow we build, from file receipt to remittance. Each step either passes the claim on or pends it with a reason.
Receive and acknowledge
The 837 file is parsed, the 999 acknowledgement is returned and each claim gets an identifier and a timestamp.
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1
Run front-end edits
Syntax, code set, duplicate and provider checks run. Failures return a 277CA rejection or pend the claim by reason.
02
2
Check member and coverage
Eligibility on the date of service, plan and product, coordination of benefits and any prior authorization on file.
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3
Apply benefit rules
Covered services, limits, accumulators and cost sharing are calculated per line, and the rule version is recorded.
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4
Price the claim
Contract terms, fee schedules and modifiers set the allowed amount, with the pricing source stored on the line.
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5
Decide or pend
Claims that meet every rule are auto-adjudicated. The rest go to a pend queue with the reason and the data needed to clear it.
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6
Pay and report
The 835 remittance and the explanation of payment are generated from the decision, and the record is kept for appeals and audits.
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7
Engineering Stack
Which standards and technologies do adjudication systems use?
The transactions, code sets and platforms behind the claims adjudication systems we build.
Transactions
X12 837P, 837I, 837D835999 and 277CA270/271278
Code sets
ICD-10-CMICD-10-PCSCPTHCPCSNDC
Rules and data
Rules enginesPostgreSQLEvent streams
Backend
JavaNode.jsPython
Infra
AWSAzure
Pend reason table
Which pend reasons should a queue design cover?
Common pend reasons, the step in the flow that raises them and what clears them. We configure the list with your claims team.
| Pend reason | Raised at | What clears it | Usual owner |
|---|---|---|---|
| Member not found or not eligible on the date of service | Member and coverage check | Enrollment correction or an eligibility span update | Enrollment team |
| Provider not on file or not contracted | Front-end edits | Provider record or contract update | Provider data team |
| Prior authorization required and not on file | Member and coverage check | A matching authorization or a medical review decision | Utilization management |
| Coordination of benefits unresolved | Member and coverage check | Other coverage confirmed or the primary payer's remittance received | Coordination of benefits unit |
| Possible duplicate claim | Front-end edits | Examiner confirms the duplicate or marks it as a corrected claim | Claims examiner |
| No pricing found for the service or contract | Price the claim | Fee schedule or contract term loaded | Contracting or configuration |
| Medical review or high-dollar threshold | Decide or pend | Clinical or supervisor review | Medical review |
Measured Impact
What should an adjudication system measure?
Measures we build reporting around, agreed with your claims team before launch.
Auto-adjudication
Share of claims decided without a touch
Claims that reach a decision with no examiner action, by claim type.
Pend aging
Days a claim waits in a queue
Time in each pend reason, so the slowest reasons are fixed first.
Rework
Claims adjusted after payment
Decisions reopened or reversed, including appeals that are overturned.
Turnaround
Receipt to remittance
Days from the 837 timestamp to the 835 file.
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Use Cases
Who builds or replaces a claims adjudication system?
Payer organizations with rules a packaged system cannot express.
02
Regional and provider-sponsored health plans
Plans whose vendor system cannot express their contracts or benefit designs.
03
TPA and insurtech startups
Claim adjudication for startups: a first release with intake, edits and pricing before full automation.
04
Dental and vision benefit administrators
837D claims with their own code sets, frequency limits and pricing.
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Workers' compensation and specialty payers
Fee schedules and bill review rules that general-purpose systems handle poorly.
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Delegated groups and IPAs
Groups that adjudicate capitated claims and report back to the health plan.
Integrations
Which systems does an adjudication system connect to?
The systems a claim touches between receipt and payment.
Intake
Clearinghouses (X12)
Membership
Enrollment and eligibility
Network
Provider data and contracts
Utilization management
Prior authorization
Finance
Payment and banking (835, EFT)
Analytics
Data warehouse and reporting
Compliance-First Development Services Backed by Global Standards
We build secure, scalable products designed for privacy, interoperability, and regulatory readiness from day one across every sector we serve.
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, and strict access controls.
Our Edge
Why Global Leaders Choose Us
We combine deep technical expertise with industry-specific knowledge to deliver solutions that aren't just functional, but transformational.
Enterprise-Grade Security
We implement rigorous security protocols and compliance standards (HIPAA, GDPR, SOC2) across all industrial solutions to protect sensitive data.
High-Performance Scaling
Our architectures are built to handle massive data loads and user bases, keeping performance steady whether you're serving ten or ten million.
Accelerated Time-to-Market
Using our suite of internal tools and proven frameworks, we reduce development cycles and get your product to market 40% faster.
Embedded AI Integration
Beyond simple wrappers, we build deep-learning integrations and predictive analytics directly into the core of your industry-specific workflows.
Engagement Model
How do we build a claim adjudication system?
How to build claim adjudication without a big-bang cutover: one claim type first, run in parallel, then widen. Timing depends on scope, and we agree it on the scoping call.
01
Scoping call
We agree the claim types, the rule sources and the systems the first release must connect to.
02
Rule discovery
We document the edits, benefit rules and pricing logic your team applies today, including the ones that live in people's heads.
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Fixed-scope first release
Intake, edits and pend queues for one claim type, run in parallel with your current system on the same claims.
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Compare and widen
Decisions are compared line by line with the current system until they match, then more claim types and rules are added.
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Support and change
Rule changes, new contracts and reporting under agreed support terms.
Facts and sources
Which rules shape claim adjudication?
Short facts behind claims adjudication systems, each linked to its primary source.
HIPAA adopts ASC X12 standards for electronic transactions, including health care claims (837), payment and remittance advice (835), eligibility inquiries (270/271) and prior authorization requests (278).
Source: 45 CFR Part 162 (eCFR)HIPAA adopts standard medical data code sets for electronic transactions, including ICD-10-CM for diagnoses, ICD-10-PCS for hospital inpatient procedures, and HCPCS together with CPT-4 for other procedures and services.
Source: 45 CFR 162.1002 (eCFR)A health plan must conduct a transaction as a standard transaction when an entity asks it to, and may not delay or reject a standard transaction, or reject it because it contains data elements the plan does not use.
Source: 45 CFR 162.925 (eCFR)The HIPAA Security Rule requires administrative, physical and technical safeguards for electronic protected health information.
Source: 45 CFR Part 164 Subpart C (eCFR)
Voice of success
We don't just build products; we forge lasting partnerships. See how we've helped industry leaders transform their vision into technical reality.
“I can clearly see how Agnotic has a unique way of handling end-to-end development. They are always active on quick chat and provide support quickly.”
Aaron Phelan
Founder, Benchmark
“Agnotic combines deep technical expertise with strong domain knowledge. They understand the business context, anticipate challenges, and make collaboration smooth and effective.”
John Pasmore
Founder, Latimer
“Agnotic is the best technical team we evaluated. Their engineering excellence made our work dramatically easier and allowed us to stay focused on what matters most for maternal care outcomes. They took full ownership of the technical execution, and we are always happy to continue working together.”
Kim Smith
Founder, My Lauren
Related services
Which related services do payers and TPAs ask about?
Detailed pages for the work that surrounds claims adjudication.
Claims processing automation
Claim intake, checks and status tracking for providers and payers.
AI claims denial management
The provider side: finding denial causes and working appeals.
X12 EDI integration
837, 835, 270/271 and 278 transactions with clearinghouses and trading partners.
Revenue cycle management software development
The provider's view of the same claim, from charge capture to payment posting.
Medical billing software development
Billing software that produces the claims adjudication receives.
RPM billing CPT codes software
Remote monitoring billing rules on the provider side of adjudication.
Software development for health plans and payers
Our payer page: CMS-0057-F APIs, prior authorization, member and provider portals.
HIPAA requirements for software teams
The safeguards we build into every system that holds member data.
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Cross-Industry Reach
The Same Engineering Patterns, Across Other Industries
The technical patterns behind this platform translate naturally into adjacent verticals.
Frequently Asked Questions
It depends on the claim types, the number of rule sources and the systems involved. We agree a fixed-scope first release on the scoping call, usually one claim type run in parallel with your current system, and give you a timeline for that release before work starts.
Yes. Claims carry protected health information, so Agnotic signs a business associate agreement with the health plan or TPA before any claims data reaches our team, and we can work inside your cloud account.
Yes. We connect to your clearinghouses through X12, to your enrollment, provider and authorization systems through their APIs or file feeds, and to your finance systems for 835 and EFT output. Those systems stay the source of truth for their own data.
Yes. A common first release is 837 intake, front-end edits and pend queues for one claim type, with benefit rules and pricing added once the decisions match your current system.
The number of claim types, how many benefit designs and contracts the rules must express, the systems to integrate, data migration from the current system and the length of the parallel run. We describe these drivers on the scoping call rather than quote a price before it.
Working knowledge of X12 837 and 835, rules your analysts can change without a developer, a parallel-run approach to cutover, and HIPAA-ready engineering with an audit trail on every decision.
AI tools help our engineers draft code, tests and rule documentation. An engineer reviews every change, and every rule is tested against claims with known outcomes before it goes live.
Industries