Payer Use Case
Verify Benefit & Reimbursement Logic Across Your Claims Stack
Health plans rely on complex benefit designs, policies, and delegated vendors. This platform translates that logic into an executable model and verifies that claims and payments follow the rules as written.
Claims This Month
847,291
Logic Verified
100%
94.2%
Correct
4.8%
Issues Found
$2.1M
Protected
The Problem
From Policy to Payment, Logic Drifts
Your benefit rules are clear. But by the time they reach the payment, they've passed through systems you don't control — each one a chance for logic to silently break.
3-5%
paid wrong
$68B+
lost/year
6-12mo
to detect
Where Logic Breaks Down
Policy
Rules documented clearly
Config
Implementation varies
Vendor
Implementation varies
Payment
Wrong amount paid
By the time you find the error through audits —
you've already paid it thousands of times.
The Gap
No Single Source of Truth
The logic that determines what a claim should pay is scattered. Each piece is managed separately, updated at different times, interpreted by different systems.
Policies
Contracts
Fee Schedules
Vendor Rules
Your Logic
Payment
What actually got paid
Execution
When you ask "did this claim pay correctly?"
there's no single place that can answer.
Your Payer Logic
Policies
Fee Schedules
Med Necessity
Verification Engine
Every claim × Every rule × Every vendor
What Surfaces
How It Works
From Policy Documents to Verified Claims
We add a verification layer above your existing systems — without replacing them. Your benefit and reimbursement logic becomes an executable specification.
Your rules become executable
Coverage policies, fee schedules, medical necessity criteria — all machine-verifiable.
Vendor outputs align automatically
PBM adjudication, TPA processing, clearinghouse data — mapped to your rules.
Every claim gets verified
Violations, vendor mismatches, and edge cases surface before payment.
No system replacement. No workflow disruption. Just visibility into whether claims follow plan intent.
What We Verify
Every Layer of Payer Logic
Each verification answers a specific question about whether the claim followed the rules as documented — not just whether it processed.
Coverage & Eligibility
"Is this member covered for this service under this plan?"
Medical Necessity
"Does this claim meet clinical criteria for coverage?"
Payment & Reimbursement
"Was the correct fee schedule and modifier logic applied?"
Vendor Alignment
"Did the PBM/TPA process this per contract terms?"
Sample Verification Output
Claim
#CLM-2024-847291
Type
Outpatient / MRI
Issue Detected
Policy MN-2024-103 requires prior auth for MRI when < 6 weeks conservative care. None on file.
This runs on
every claim, automatically
Illustrative Examples
The Kind of Issues Verification Catches
These scenarios represent common patterns that surface when benefit logic is verified against actual claims.
Policy Drift
Updated policy, but claims engine still running old rules
Medical necessity policy MN-2024-103 was updated in January to require prior auth for MRI when < 6 weeks conservative care. The claims engine wasn't updated until March.
What Verification Surfaces
Root cause: Policy update process doesn't automatically trigger system configuration review.
These examples are illustrative. Actual findings depend on your specific policies and systems.
The Outcome
From Reactive Discovery to Proactive Protection
Payers using logic verification shift from finding errors after payment to preventing them before they happen.