Know the Exact Payment — Before You Pay
Stop guessing what claims should cost. Our platform verifies every claim against your contracts, fee schedules, and policies — surfacing the exact payment amount and any rule deviations.
Memorial Hospital
Dec 10, 2024
$12,450.00
Blue Cross PPO
Every claim verified against contract rules
The Problem
Rules Are Written Once — Enforced Everywhere
Benefit and reimbursement logic is defined in documents and contracts, but applied across fragmented systems, vendors, and workflows.
Contract Language
“Modifier 59 applies when procedures are performed on distinct anatomical sites during the same session.”
Interpreted by
System Implementations
Same rule, three systems, three different outcomes
Edge Cases Slip Through
Complex rule combinations and exceptions create blind spots that manual review and rule engines miss.
Systems Drift Apart
The same rules get implemented differently across claims, adjudication, and payment systems.
Errors Surface Late
Problems are discovered during audits or complaints — long after payments have been made.
Our Approach
Make the Rules Executable
Instead of inspecting outcomes after the fact, we verify the logic itself.
Model the Logic
Plan language, policies, and contractual clauses become precise, machine-checkable rules.
SPD Section 4.2 → Formal rule set
Map to Reality
Claims, determinations, and payments are aligned to the model.
Claim #2024-847 → Rule inputs
Verify Behavior
Violations, gaps, and edge cases are surfaced automatically — before payments go out.
Proof of correctness or violation
What We Verify
Any Logic That Determines Payment
If a rule determines an outcome, it can be modeled and verified.
Eligibility & Coverage
Verify member status and service coverage before claims are processed.
Authorization Logic
Ensure prior auth and medical necessity rules are applied correctly.
Reimbursement Rules
Validate pricing calculations match contracted terms.
Edge Cases
Catch the complex scenarios that slip through rule engines.
Use Cases
Contracts We Verify
Any document that defines payment logic can be modeled and verified.
Plan Documents
SPDs, benefit summaries, coverage policies, and plan amendments.
What gets verified
Who It's For
Built for Healthcare Operations
Anyone who relies on contract logic to determine coverage, payments, or reimbursements.
Payers
Health plans, TPAs, and self-insured employers verifying claims match benefit rules before payment.
Providers
Health systems and provider networks confirming contract terms are applied correctly.
PBMs
Pharmacy benefit managers validating drug pricing, formulary rules, and rebate calculations.
Manufacturers
Life sciences companies auditing rebate and reimbursement accuracy.
The Difference
Catch Issues Before They're Processed
Don't wait for audits to find problems. Verify correctness at submission.
Traditional
Process Now, Audit Later
Verification
Verify Before Processing
Ready to Verify Your Claims Logic?
See how your benefit rules translate into verified, provable outcomes — before errors turn into spend.