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Intelligent pend resolution
Apply targeted intelligence to every pended claim so reviewers engage only where judgment changes the outcome.
AI classified
Pend classification
Categorize each pended claim into duplicate claims, COB, member eligibility, high dollar review, medical necessity and others with the help of AI.
Specialist agents
Targeted agent routing
Route each pended claim to an AI agent trained on the specific rules, evidence requirements, and resolution criteria relevant to that claim type.
Rationale included
Suggested determination
Agents apply targeted logic such as COB sequencing rules, eligibility records, clinical guidelines, financial thresholds and standard operating procedures to generate suggested determination with rationale.
Gap closure
Missing data resolution
Identify data gaps, retrieve available records from connected systems, and resubmit for adjudication where possible, reducing pends caused by missing or incomplete information.
Human in the loop
SME approval
Route complex and borderline cases to a subject matter expert with the full claim record, AI rationale, and supporting evidence pre-assembled.
Audit ready
Adjudication audit trail
Log every resolved pend, automated or SME-reviewed, with AI rationale, reviewer identity, and final decision for RADV and CMS audit readiness.
