Health plans
Medical claim adjudication across commercial and government lines.
Claims Processing Automation
Claims Processing Automation
We build claims engines that ingest EDI 837, adjudicate against plan rules, and return 835 remittance with minimal human touch — plus a denial-prediction model that flags problems before they become appeals.
HIPAA-ReadyEDI X12 5010SOC 2 Type IIAudit Logged
Trusted by global innovators
Why manual adjudication doesn't scale
For payers, TPAs, and self-funded administrators, every claim that drops to manual review costs money and time. The bottleneck is rarely the payment itself — it's the intake parsing, the eligibility and benefit matching, the plan-rule evaluation, and the pended-claim triage that eat examiner hours. Legacy adjudication systems handle the easy claims and dump the rest into a queue.
We build claims automation that raises the straight-through-processing rate: EDI 837 intake normalized and validated on arrival, benefit and provider matching automated, plan and pricing rules evaluated in a transparent engine, and edge cases routed with the reason they pended. A denial-prediction layer catches likely rejections upstream so they can be corrected instead of appealed.
What it is
Adjudication without the examiner bottleneck
Claims processing automation takes an inbound claim from EDI intake through eligibility, benefit, and pricing evaluation to a payment or denial decision — with as little manual handling as the plan rules allow.
The measure of success is the straight-through-processing rate and the accuracy of the automated decisions. We build engines that are both fast and explainable, so examiners handle genuine exceptions and every decision withstands audit.
From 837 intake to 835 remittance
Auto-adjudication, rules transparency, and denial prediction in one pipeline — so examiners work the exceptions, not the routine.
What we build into your claims engine
Each capability pairs an automation outcome with the EDI standard or rule mechanism behind it.
EDI 837 intake & normalization
Inbound professional, institutional, and dental claims parsed from the X12 5010 837 format, validated against structural and business edits, with 999 and 277CA acknowledgments returned to submitters automatically.
Auto-adjudication engine
A transparent rules engine that evaluates eligibility, benefits, provider network status, and pricing to adjudicate clean claims straight through, pending only the ones that genuinely need an examiner.
Denial prediction & prevention
A model that scores incoming claims for denial likelihood by procedure, diagnosis, and provider pattern, surfacing correctable issues before adjudication so avoidable denials never hit the appeal pipeline.
835 remittance generation
Electronic remittance advice produced in the X12 835 format with accurate CARC/RARC reason codes, adjustments, and payment details reconciled to the adjudication result.
Fraud, waste & duplicate detection
Duplicate-claim logic, unbundling and upcoding flags, and anomaly detection integrated into the adjudication flow, with a full audit trail on every automated decision.
Examiner workbench & analytics
Pended claims routed with a plain-language reason and the rule that triggered them, plus dashboards for STP rate, turnaround time, and denial categories to tune the engine over time.
Where it runs
Claims automation use cases
Third-party administrators
Multi-client adjudication with plan-specific rule sets.
Self-funded employers
Automated processing for self-insured benefit plans.
Dental & vision
Specialty adjudication with 837D and plan-specific benefit logic.
Pharmacy benefit workflows
Coordinated adjudication alongside medical claims.
Reinsurance & stop-loss
High-cost claim identification and downstream reporting.
Where claims automation pays off
The lever is straight-through-processing rate. We instrument it end to end so gains are measurable — targets are validated against your claim mix in discovery.
STP
Straight-through-processing rate is the primary lever
837/835
Native EDI intake and remittance
100%
Automated decisions carry an audit trail
Compliance-First Healthcare App Development Services Backed by Global Standards
15-Minute Scoping Call01
HIPAA
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, strict access controls, and traceable audit logs.
02
GDPR
General Data Protection Regulation
Implement lawful consent flows, data minimization, retention controls, and secure processing for sensitive health data.
03
FHIR
Fast Healthcare Interoperability Resources
Enable standardized health data exchange across apps, care teams, and systems through robust FHIR-ready APIs.
04
HL7
Health Level Seven International
Support enterprise-grade interoperability with HL7-based integrations for records, events, and clinical messaging workflows.
05
HITRUST
Health Information Trust Alliance
Align security programs to healthcare-specific control and risk management practices trusted by providers and ecosystem partners.
06
HITECH
Health Information Technology for Economic and Clinical Health Act
Design with breach notification readiness, digital record safeguards, and operational controls that support regulated care programs.
07
SaMD
FDA Software as a Medical Device
Plan software quality, traceability, and documentation pathways for products that may require SaMD review and submission.
08
MDR (EU)
Medical Device Regulation (European Union)
Prepare EU market-ready processes for risk classification, evidence tracking, and lifecycle governance under MDR expectations.
09
SAMHSA
Substance Abuse and Mental Health Services Administration
Apply confidentiality controls and consent-aware sharing models for behavioral and mental health data experiences.
Standards we build against
Claims automation standards
X12 837X12 835X12 276/277CARC / RARCHIPAAHITECH
Our Process
How we deliver a claims automation build
Intake, rules, and remittance are built and validated in parallel against real 837 samples.
1.
Adjudication discovery
We map your plan designs, current STP rate, pend reasons, and examiner workload, then design the rules model and the automation boundary before building.
Rules-transparent
2.
Intake & rules engine
We build 837 intake, validation, and the auto-adjudication rules engine, testing against real claim samples to confirm decisions match your policy.
5010-compliant
3.
Prediction & remittance
The denial-prediction layer and 835 generation, with the examiner workbench for the exceptions the engine intentionally pends.
Straight-through
4.
Go-live & STP tuning
Phased launch with STP-rate and turnaround dashboards, plus ongoing rule and model tuning as plan designs evolve.
Always audit-ready
Featured case study
Read Case StudyLera Health: compliant women's health platform
Related proof of compliant delivery: Lera Health is a patient-facing platform, not a claims engine, but building its secure, auditable data layer demonstrates the PHI handling and decision-traceability rigor an adjudication system requires.
Why Partner With Us
15-Minute Scoping CallWhy payers pick Agnotic for claims automation
We bring EDI adjudication depth and explainable-automation engineering so your STP rate rises without losing auditability.
Auditable by Design
Every automated decision carries the rule and data that produced it — built for compliance review, not opaque black-box logic.
EDI Adjudication Depth
837 intake, 835 output, CARC/RARC semantics, and pricing logic are our starting point, not a learning curve billed to you.
STP That Actually Moves
We target measurable straight-through-processing gains validated against your real claim mix, not demo data.
Explainable Automation
Prediction and adjudication that examiners can understand and override, so trust in the system grows instead of erodes.
Our relevant experience
Adjudication that scales without losing the audit trail
Frequently Asked Questions
A core adjudication engine with 837 intake, a configurable rules engine, and 835 output typically starts in the mid six figures given the complexity. Adding denial prediction, FWA detection, and multi-plan support extends it. We scope against your plan designs and claim volume in discovery.
Ready to raise your straight-through rate?
Tell us your plan designs and current STP rate. We'll return a claims-automation plan with rules scope, prediction approach, and a realistic timeline.
contact@agnotic.com
Partnerships
contact@agnotic.com