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 5010X12 835Audit Logged
Trusted by global innovators
What is claims processing automation?
Claims processing automation is software that takes a health care claim from EDI 837 intake through eligibility, benefit and pricing rules to a payment or denial decision, with as little manual handling as the plan rules allow. Agnotic Technologies builds these engines for payers, TPAs and self-funded plans, with every automated decision logged for audit.
The bottleneck is rarely the payment: intake parsing, eligibility and benefit matching, plan-rule evaluation and pended-claim triage eat examiner hours. We raise the straight-through-processing rate with validated EDI 837 intake, a transparent rules engine, reasons on every pended claim and denial prediction upstream.
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 goes into a claims automation 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
Who uses claims processing automation?
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 does claims automation pay 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
Audited
Every automated decision carries 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 standards-based FHIR 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
Which standards does a claims engine follow?
X12 837X12 835X12 276/277CARC / RARCHIPAAHITECH
Our Process
How do we build claims processing automation?
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
Facts and sources
Which rules shape claims processing automation?
Short facts we design claims engines around, 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)A HIPAA covered entity may share protected health information with a business associate, such as a software vendor, only under a business associate agreement that commits the vendor to safeguard it.
Source: 45 CFR 164.502(e) and 164.504(e) (eCFR)The HIPAA Security Rule requires administrative, physical and technical safeguards for electronic protected health information.
Source: 45 CFR Part 164 Subpart C (eCFR)The NIST AI Risk Management Framework is a voluntary framework that organizes AI risk work into four functions: Govern, Map, Measure and Manage.
Source: NIST AI 100-1
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 do payers choose 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
Cost is driven by the number of plan designs and rules you automate, claim volume, and whether denial prediction, FWA detection and multi-plan support are in the first release. We scope against your plan designs and claim volume in discovery and give a fixed estimate.
Adjudication rules drive the timeline, along with access to real claim samples and the core admin system. We validate the rules engine against those samples throughout and stage delivery so a subset of clean claims can auto-adjudicate in a test environment early.
Yes. Agnotic signs a business associate agreement before any claim data is shared, and development and test environments use synthetic or de-identified claims. HIPAA safeguards such as encryption, role-based access and audit logging are built in from the first sprint.
Yes. We scope the first release to one workflow, such as 837 intake and auto-adjudication of clean claims for one plan type, with exceptions routed to examiners. Denial prediction, more plan types and remittance follow on the same base.
AI tools help our engineers draft code and tests, but a person reviews every change, and it passes the same automated tests and security checks as any other code, including regression tests on adjudication rules. Which tools may see your code or data is agreed with you at the start.
Buy a core administration platform if standard adjudication fits your plans. Build, or build alongside, when you need a differentiated STP rate, custom plan designs, or a denial-prediction and FWA layer that packaged systems don't offer. Many clients wrap automation around an existing core.
We integrate over EDI (837 in, 835 out, 276/277 status) and via APIs to your member, provider, and benefit-configuration systems. The automation layer can front-end an existing core, adjudicating clean claims and passing genuine exceptions through with full context.
The model scores each incoming claim for denial likelihood using procedure, diagnosis, provider, and historical adjudication patterns. High-risk claims with correctable issues are flagged before adjudication, so avoidable denials are prevented rather than appealed later.
Yes. Each adjudication carries the rule version, input data, and reason codes that produced it, and PHI is encrypted at rest and in transit with role-based, logged access. That record supports regulatory and internal audit review.
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