🏛️ For Payers

Autonomous AI for
Payer Operations

Cut claims processing time by 80%, eliminate manual pre-authorization, and detect fraud before it costs you all from one AI-native platform built for Indian health insurance.

Request Demo → See Features
🤖 AI Claim Adjudication ✅ NHCX Connected 🔍 Fraud Detection
Zive Claims Agent · TPA Processing
// Claim received from NHCX → claims.ingest("CLM-884211") type: Cashless IPD amount: ₹1,24,000 policy: POL-SUD-88421   // AI validates policy & benefit → claims.adjudicate() eligibility: verified ✓ fraud_score: 0.03 (clear) deductible: ₹5,000 applied   → claims.settle() approved: ₹1,19,000 payment: queued ✓ elapsed: 8.4s
80%Faster claim processing
90%Reduction in manual ops
99%Pre-auth accuracy rate
₹2Cr+Fraud savings per quarter
Who We Serve

Built for every type of
payer organisation

Whether you're a large insurer or a lean TPA, Zealthix scales to your claims volume and compliance requirements.

🏦Insurance Companies
🔄Third-Party Administrators
🏢Corporate Self-Insured Plans
🏛️Public Sector Undertakings
The Problem

Payer operations are
drowning in manual work

⏳

Slow Claims Processing

Manual claim review takes 7–14 days. Providers lose trust, members get frustrated, and administrative costs spiral out of control.

🚨

Fraud & Revenue Leakage

Without AI detection, 5–10% of claims paid are fraudulent or inflated. That's crores lost every quarter across your network.

📝

Manual Pre-Authorization

Phone-based pre-auth creates bottlenecks, delays patient care, and consumes hospital and payer admin resources simultaneously.

📂

Unstructured Policy Data

PDF policies with unstructured benefit tables make real-time benefit verification at the point of care impossible without AI extraction.

🔌

Disconnected Systems

Claims, policy, provider network, and analytics living in silos. No single source of truth slows every decision and audit.

📊

No Real-Time Visibility

Batch reports with a 24-hour lag mean you're always reacting to problems rather than catching them before they cost you.

Our Solution

How Zealthix transforms
payer operations end-to-end

🤖

Automated Claims Adjudication

AI agents validate, adjudicate, and settle claims in minutes. Rules-based plus ML validation auto-approves 80% of standard claims with full audit trail.

⚡

Instant Pre-Authorization

Hospitals submit pre-auth requests digitally. Our AI engine cross-references policy terms, medical necessity criteria, and historical data to approve in under 10 seconds.

🔍

AI Fraud & Abuse Detection

Anomaly detection models flag suspicious claims before payment. Pattern analysis across your entire network identifies organized fraud rings and serial offenders automatically.

📋

Digital Policy Management

Digitize every policy, benefit, and exclusion. AI extracts structured terms from PDF policies making them machine-readable for real-time benefit verification at point of care.

🏥

Cashless OPD Administration

End-to-end cashless outpatient plans from digital card issuance to real-time authorization at provider networks. Zero paper, zero delays, zero leakage.

📈

Analytics & Loss Ratio Control

Real-time dashboards on claims ratio, fraud loss, TAT, and member health. Predictive models forecast trend changes before they impact your loss ratio.

How It Works

From claim receipt to
settlement in minutes

Zealthix connects to your existing NHCX gateway, policy system, and provider network. No rip-and-replace the AI layer sits on top and immediately starts reducing TAT and leakage.

1
Claim Received via NHCX

Claims arrive digitally from hospitals through the NHCX gateway. Structured data eliminates manual data entry and document scanning entirely.

2
AI Policy & Eligibility Check

The adjudication engine instantly verifies coverage, deductibles, exclusions, and waiting periods against the digitized policy in milliseconds.

3
Fraud Scoring & Validation

ML models score the claim for fraud probability, upcode detection, and duplicate checks before any approval decision is made.

4
Auto-Approve or Route for Review

Clean claims are auto-approved and queued for payment. Edge cases are routed to your reviewers with AI-generated summaries cutting review time by 70%.

Insurance claims processing dashboard
Products Used

Zealthix products
powering payer solutions

⚡
Zive Claims & Policy AI

Core AI engine for claim adjudication, pre-authorization, fraud detection, and digital policy management.

Core Product
🗄️
Zlake Health Data Lake

Aggregates member records, claim history, and provider data into a unified health data platform for analytics.

Key Product
📊
Zudy Adjudication Engine

Real-time dashboards, loss ratio forecasting, and fraud analytics visualized for your operations and leadership teams.

Supporting
📋
Contract Management

Automate payer-provider agreements, tariff management, and contract renewal workflows with AI assistance.

Supporting
🛡️
AI Claim Underwriting

Risk-score individual claims and member cohorts at underwriting stage reducing adverse selection and surprise losses.

Key Product
🔎
Abuse Management

Detect provider-side billing abuse patterns, duplicate investigations, and claim frequency anomalies before payment.

Key Product
📁 Case Study

Leading TPA reduces claim TAT from 14 days to 18 hours

A major Third-Party Administrator processing 50,000+ claims/month deployed Zealthix's AI claims engine and pre-authorization module. Measurable results within 60 days of go-live.

Read Full Case Study →
93% Reduction in claim TAT
₹2Cr Fraud savings in Q1
40% Lower admin cost
60d Time to value
Ready to transform?

See Zealthix in action
for your payer organisation

Book a 30-minute demo tailored to your claims volume, team size, and compliance requirements.

Book Demo → Talk to Sales