📄 Claims & Insurance

Policy & Claims

Fully automated claim adjudication, digital policy management, and AI fraud detection reducing claim TAT from 14 days to hours and cutting manual ops by 90%.

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✅ NHCX Integrated 🤖 AI Adjudication 🔍 Fraud Detection
Claims Agent · Claim #CLM-209341
// Hospital submits claim via NHCX → claims.receive("CLM-209341") provider: Manipal Hospital, Bengaluru diagnosis: Coronary Artery Disease (I25.1) billed_amount: ₹3,42,000   // Policy validation → claims.validate_policy() policy: active ✓ waiting_period: satisfied ✓ diagnosis_covered: yes ✓   // AI fraud + tariff check → claims.adjudicate() fraud_score: 0.03 (low risk) tariff_admissible: ₹3,18,500 deductible: ₹5,000 approved: ₹3,13,500 ✓ elapsed: 6.2s
80%Claims auto-adjudicated without human review
93%Reduction in claim turnaround time
99%Pre-authorization accuracy
₹2Cr+Average quarterly fraud savings
Features

Claims that process themselves.
Fraud that never gets paid.

🤖

Automated Claim Adjudication

Rules engine plus ML models validate, cross-reference, and adjudicate claims in seconds. 80% of standard claims settled without a human reviewer touching them.

📋

Digital Policy Extraction

AI extracts structured benefit terms from any PDF policy coverage rules, exclusions, co-pays, waiting periods making them machine-readable for instant claim validation.

⚡

Instant Pre-Authorization

Hospitals submit pre-auth requests digitally via API or portal. AI cross-references policy terms and historical data to approve or escalate in under 10 seconds.

🔍

AI Fraud Detection

Anomaly detection flags duplicate claims, inflated bills, phantom procedures, and network fraud rings before payment is approved, reducing fraud leakage by up to 90%.

🌐

NHCX Connectivity

Native integration with the National Health Claims Exchange. Receive provider claims, communicate decisions, and confirm settlements through the standardized national network.

📊

Claims Intelligence Dashboard

Real-time visibility into claim volumes, approval rates, TAT, fraud flags, and settlement status. Predictive analytics forecast claim trends and portfolio loss ratio.

How It Works

From NHCX submission
to settlement in hours

Policy & Claims replaces the manual, phone-based claims workflow with a fully digital, AI-driven process. Providers get faster settlements. Payers get lower costs and less fraud.

1
Claim Received via NHCX

Hospital submits the claim through NHCX or directly via the Zealthix provider portal. All supporting documents attach digitally no courier, no fax.

2
Policy & Eligibility Validation

AI checks policy status, benefit eligibility, waiting periods, and pre-auth linkage in milliseconds. Missing information triggers automated document requests.

3
Adjudication & Fraud Check

Claims are adjudicated against tariff schedules, policy terms, and fraud models simultaneously. 80% are approved automatically; complex cases route to reviewers with AI summaries.

4
Settlement & Reporting

Approved claims are queued for settlement. Provider receives digital settlement advice. All decisions are logged with reason codes for audit and IRDA compliance.

Insurance claims processing and analytics
Impact

Measurable ROI from
day one of deployment

93%
Reduction in claim TAT (from 14 days to 18 hours)
₹2Cr
Average fraud savings in Q1 for a mid-size TPA
60d
Time to measurable ROI post go-live

Cut your claims TAT.
Eliminate fraud losses.

Book a demo tailored to your claims volume and team size. We'll calculate your ROI projection in the session.

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