Intelligent Operating System For Healthcare Claims

Transparent claimsoperations built forspeed, trust, and explainable decisions

ClaimHeart is a healthcare claims intelligence platform for intake, review, policy reasoning, fraud controls, explainable decisions, and stakeholder communication across the full claim lifecycle.

"Built for healthcare claims teams that need automation without losing control or clarity."

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See How It Works

Designed for insurers, hospitals, TPAs, and patient-facing operations teams

Workflow synced

Intake, RAG, review, and notification

ClaimHeart live console

Operational trace from intake to decision

Hospital intakeRAG groundingInsurer reviewPatient update

> Intake session initialised for pre-auth package

> OCR scan complete - 5 documents normalised

> RAG retrieval matched policy clauses 3.2, 5.2, and 6.4

Trusted by

Star Health

HDFC ERGO

Bajaj Allianz

ICICI Lombard

Niva Bupa

Star Health

HDFC ERGO

Bajaj Allianz

ICICI Lombard

Niva Bupa

Star Health

HDFC ERGO

Bajaj Allianz

ICICI Lombard

Niva Bupa

Average Decision Support Cycle

Structured intake to recommendation

High-Risk Claim Detection

Signal-driven anomaly identification

Operational Throughput Gain

Automation across review stages

Rs0Cr

Potential Leakage Prevented

Better controls across claim decisions

Why Claims Operations Need Reinvention

Legacy claims workflows are slow, opaque, and fragmented across stakeholders. Modern teams need a system built for speed, control, and explainability.

1 in 5

Claims Denied

Every year, millions of legitimate claims are rejected due to coding errors and documentation gaps.

80%

Data Unstructured

Insurance data lives in scanned PDFs, handwritten forms, and siloed systems that are difficult to process efficiently.

$68B

Annual Fraud Loss

Ghost billing, upcoding, and phantom services drain billions from the healthcare system annually.

Patient Transparency

Patients receive denial letters with no explanation, no recourse, and no clarity on what went wrong.

Platform Architecture

A modular claims intelligence stack designed to support intake, review, coordination, and explainable decision-making at scale.

OCR + Structuring

Intake Engine

Transforms uploaded hospital documents into a structured intake pack with scanning, extraction, and packaging visuals.

RAG Grounded

Policy Agent

Retrieves the right policy clauses, waiting-period rules, and coverage checks with explicit evidence grounding.

Clinical Review

Medical Agent

Checks diagnosis consistency, protocol adherence, and treatment justification against the submitted medical evidence.

Evidence Reconciliation

Cross Validation Agent

Reconciles prescription, billing, labs, and decision output into a final recommendation with an explainable audit trail.

Workflow Orchestration

A connected workflow spanning document intake, evidence grounding, adjudication, escalation, and communication.

STEP 01

Hospital Upload

The hospital uploads pre-auth, prescription, lab, policy, and billing documents into the intake pack.

STEP 02

Intake Scan

ClaimHeart runs staged OCR, extraction, and packaging so the workflow looks and behaves like a live intake pipeline.

STEP 03

RAG Grounding

Relevant policy clauses and treatment evidence are retrieved before insurer review begins.

STEP 04

Sequential Review

Policy, medical, and cross-validation agents execute one after another with visible audit signals.

STEP 05

Decision + Update

A final decision letter is generated, synced to dashboards, and queued for patient communication.

Why Teams Build On ClaimHeart

Designed as a durable operating layer for healthcare claims, not a point solution for one workflow step.

Glass-box AI

Every decision is explainable. Full audit trail. No black boxes.

Real-time Fraud

Sub-second fraud scoring on every claim instead of delayed batch checks.

Policy Citations

Exact page and clause references for every coverage recommendation.

Human-in-loop

AI recommends, humans decide. Escalation workflows are built in.

Operational Outcomes

Performance improvements that matter across insurers, providers, TPAs, and care operations teams.

18 sec

Average Processing Time

Down from 60-90 days of manual review

90%

Fraud Detection Accuracy

Combining ML anomaly detection and LLM reasoning

10x

Faster Than Manual

End-to-end automation across all claim types

What Claims Leaders Are Saying

Simple, readable feedback from people thinking about claims operations, review quality, and patient communication.

"ClaimHeart brings structure to every stage of the claim journey. What stood out most was how clearly the platform connects intake, review, and decision visibility in one system."

Sachin Manral

Claims Strategy Lead

Healthcare Claims Operations

"The workflow feels operationally mature. Instead of isolated tools, ClaimHeart gives teams a dependable layer for evidence review, coordination, and explainable decision support."

Sandeep Parjapati

Insurance Workflow Manager

Digital Adjudication Team

"What makes ClaimHeart compelling is the balance between automation and control. Teams move faster without losing auditability, oversight, or confidence in the final outcome."

Vaibhav Yadav

Head of Claims Transformation

Payer Innovation Office

"Most platforms stop at internal processing. ClaimHeart stands out because it extends the experience through patient-facing clarity, communication, and a much more transparent decision trail."

Urja Gunjan

Patient Experience Architect

Care Operations Program

"ClaimHeart feels like a long-term product, not a point demo. The architecture, presentation, and workflow logic all suggest a platform designed to keep evolving without losing coherence."

Vyakhya Namdev

Platform Design Reviewer

Claims Intelligence Practice

Frequently Asked Questions

The core questions teams ask when evaluating a long-term healthcare claims platform.

Ready to Modernize Claims Operations?

Adopt a unified operating layer for intake, review, explainable AI decisions, fraud controls, and patient-facing communication.

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