🤖 Adjudication AI

Zudy

The AI-driven automated OPD and IPD adjudication platform for payers AI decisions on every claim, zero manual review for standard cases, and real-time fraud and leakage detection built in.

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🤖 AI Adjudication ✅ OPD + IPD 🛡️ Fraud Detection
Zudy Agent · Claim Adjudication
// IPD claim received for adjudication → zudy.adjudicate("IPD-CLM-29104") type: IPD · Cardiac Surgery claimed: ₹2,40,000   // AI runs multi-layer checks → zudy.evaluate() eligibility: active ✓ policy_coverage: cardiac covered ✓ tariff_check: within network rate ✓ fraud_score: 0.06 low risk leakage_flags: none ✓   → zudy.decide() approved: ₹2,18,500 deductions: ₹21,500 non-payable elapsed: 4.7s
97%OPD claims auto-adjudicated without human review
4.7sAverage IPD adjudication decision time
35%Reduction in fraudulent claim payouts
OPD+IPDUnified adjudication platform
Features

Every claim decided by AI
OPD and IPD, end to end

⚡

Automated OPD Adjudication

Rules-based and ML adjudication decides 97% of OPD claims without any human intervention. Eligibility, benefit coverage, copay calculation, and provider tariff checks simultaneous and instant.

🏥

IPD Claim Intelligence

AI-powered IPD adjudication handles complex hospitalization claims DRG benchmarking, package rate validation, length-of-stay norms, implant checks, and pre-auth reconciliation in seconds.

🛡️

Fraud & Leakage Detection

Every claim scored for fraud risk at submission using ML trained on Indian health claims data. Duplicate detection, over-billing patterns, phantom visits, and network abuse flagged before payment is made.

🔍

Intelligent Escalation

Claims that fall outside auto-adjudication thresholds are automatically escalated to the right reviewer with a pre-populated decision context cutting review time by 70% for complex cases.

📋

Policy & Benefit Engine

Zudy's benefit engine enforces the exact policy configuration waiting periods, sub-limits, co-insurance, disease-specific caps, and exclusion lists applied with zero drift from the policy document.

📊

Adjudication Analytics

Full visibility into claim decisions, approval rates, denial reasons, fraud flags by provider, and SLA performance all in real-time dashboards for operations and finance teams.

How It Works

From claim submission
to AI decision in seconds

Zudy sits between claim receipt and payment making every adjudication decision automatically, and routing only genuinely complex cases to human reviewers.

1
Claim Received

OPD or IPD claim arrives via NHCX, direct API, or TPA portal. Zudy enriches the claim with member history, policy details, and provider data automatically.

2
AI Runs Multi-Layer Evaluation

Eligibility, coverage, tariff compliance, fraud scoring, and leakage detection run in parallel. Every check completed in under 5 seconds regardless of claim complexity.

3
Decision or Escalation

Standard claims approved or denied automatically with a full audit trail. Complex claims escalated with AI-generated decision context reviewers act on evidence, not data entry.

4
Payment Instruction Issued

Approved amounts flow directly to the payment and settlement layer. Denial advice generated automatically and sent to providers no manual letter writing.

AI adjudication platform dashboard for payers
Impact

Fewer reviewers, faster decisions,
less leakage

97%
OPD claims fully adjudicated by AI without human intervention
35%
Reduction in fraudulent and inflated claim payouts
70%
Faster review time for escalated IPD claims with AI-prepared context

Automate your adjudication
stack OPD and IPD

Book a demo and we'll show you Zudy adjudicating live claims from your portfolio OPD in under 5 seconds, IPD in under 30.

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