Claims denials cost health plans billions annually. The root cause isn’t usually the claims engine; it’s the configuration data feeding it. Manual keying errors, outdated provider terms, and misaligned benefits data create cascading denials. Traditional approaches fix symptoms; they don’t address the systemic workflow and process breakdowns that cause them.
Simplify Alpha™ deploys Claims1™.Intellect, which autonomously manage claims adjudication. Claims1™ enables claims configuration, validation, and deployment. Process Mining continuously monitors the claims lifecycle to surface bottlenecks, variant deviations, and non-conformance. The result is a closed-loop system, from intelligent adjudication to automated root-cause analysis, that improves with every claims cycle driving 40 to 60% cost reduction.
Measurable Business Outcomes
- Agentic Claims Decisioning: AI agents that read clinical context, match policy rules, and resolve claims autonomously using multiple reasoning engines working in concert
- Smart Workflow Orchestration: Automated routing, assignment, and exception handling that gets the right claim to the right resource at the right time
- Configuration QA & Testing: Pre-adjudication validation across core admin platforms before changes hit production
- Zero-Touch Data Integration: Clean benefits and provider data flow directly into claims configuration, eliminating manual keying and the errors that come with it
- Process Intelligence: End-to-end claims lifecycle visibility with bottleneck detection, cycle time benchmarking, conformance monitoring, and variant analysis
- Closed-Loop Improvement: Denial root-cause analysis, configuration drift detection, and automated remediation that make theoperation smarter with every cycle
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