What’s in scope.
The list below describes the standard work breakdown. Every engagement is scoped to client volume, line of business, and platform. Bespoke scope is the default, not the exception.
- 01
Auto-Adjudication Uplift
Edit-resolution agents that close the gap between your current first-pass rate and the platform’s theoretical ceiling.
- 02
COB & Eligibility Validation
Real-time COB queries, Medicare crossover handling, and other-payer detection from member EHR signals.
- 03
Edit & Reject Resolution
Pend-and-park resolution at scale: automated where deterministic, escalated where judgment is needed.
- 04
Stop-Loss Data Integrity
Catastrophic claim flagging, specific and aggregate stop-loss reporting, and reinsurance file preparation.
- 05
Fraud, Waste & Abuse
Provider outlier detection, member-level FWA scoring, and SIU case packaging with documentation.
- 06
Configuration Audits
Benefit-plan configuration audits — catch the misconfigurations that cost you basis points before open enrollment.