ClaimSense™: Explainable AI Adjudication for Health Claims
Transform 50-page unstructured hospital claim files—handwritten notes, pharmacy invoices, lab telemetry, and discharge summaries—into fully auditable, rupee-itemized Evidence Cards in under 120 seconds.
From 28 Minutes of Manual Reading to 2 Minutes of Auditable AI
Claims teams are overwhelmed by millions of messy PDFs, poor-quality hospital phone photos, and illegible clinical notes. ClaimSense™ creates an automated evidence map.
Straight-Through Processing (STP)
Fully compliant, low-risk claims matching exact tariffs and biometry records are auto-cleared for instant settlement without manual human intervention.
Adjudicator Throughput Surge
Claims officers no longer cross-reference rate cards or hunt through hospital PDFs; ClaimSense™ highlights the exact clauses and discrepancies.
Defensible Audit Trails
Every rupee deduction links back to an exact contract line item, hospital MOU section, or medical diagnostic telemetry file.
Every Finding Gets an Evidence Card
Instead of producing vague "Risk Scores", ClaimSense™ decomposes the entire claim into atomic Evidence Cards that medical reviewers and financial officers can accept, reject, or escalate with one click.
- Source Citation: Highlights the specific hospital invoice page and rate card contract clause.
- Mathematical Impact: Exact rupee variance (e.g. ₹86,600 unbundled catheter overcharge).
- Confidence Score: Grounded algorithmic probability based on verified medical dictionaries.
- Auditable Action Log: Preserves claims officer decisions for IRDAI regulatory inspections.
Clinical Consistency Engine
Validates whether the clinical documentation, lab telemetry, and diagnostic imaging truly support the billed treatment.
Diagnosis vs. Procedure
Cross-checks ICD-10 codes against CPT intervention standards to flag unjustified surgical escalations for mild ailments.
Lab Telemetry Validation
Verifies if cardiac enzyme markers (Troponin I), blood gas levels, or pathology values support ICU admissions and critical care codes.
DICOM Imaging Telemetry
Inspects angiogram stenosis percentages, X-ray fracture patterns, and MRI metadata to confirm procedural necessity.
Pharmacology Drug Regimen
Identifies contradictory drug combinations, excessive antibiotic dosages, or ghost-invoiced specialty biologic medications.
Plug ClaimSense™ Directly into Your Claims Workflow
Available via sub-second REST APIs, webhook connectors, or embedded within your core policy administration portal.
Evaluate ClaimSense™ on Your Claims Pipeline
Schedule an enterprise demonstration with our AI engineering team and run a retrospective trial on historical claim batches.