Claims Processing System
Claims processing systems are the operational core of health insurance — adjudicating medical claims at scale under complex coverage rules, regulatory requirements, and anti-fraud mandates that most technology vendors have never encountered.
Healthcare claims processing is the workflow by which health insurers (payers) receive, validate, adjudicate, and pay claims submitted by providers for services rendered to members. A claims processing system must apply coverage rules to determine whether a claim is covered, calculate the payer's payment obligation based on contracted rates and member cost-sharing, coordinate benefits with other insurers, detect fraudulent or abusive billing patterns, and generate explanation of benefits (EOB) documents for both providers and members. At large payers, this happens at a rate of millions of claims per day.
Claims processing technology is governed by multiple regulatory frameworks simultaneously. CMS requires electronic claims submission in HIPAA standard transaction formats (837P for professional claims, 837I for institutional claims, 835 for electronic remittance). State mandates govern timely payment — most states require clean claims to be paid within 30 days. The ACA's medical loss ratio requirements constrain payer overhead — claims adjudication efficiency directly affects regulatory compliance. Prior authorization requirements, which are governed by CMS interoperability rules, must be automated for certain high-volume procedures.
The most technically demanding aspects of claims processing are coordination of benefits and fraud detection. Coordination of benefits (COB) requires determining payment responsibility when a member has coverage from multiple payers — a process that requires real-time data exchange with other payers and complex rule application. Fraud, waste, and abuse (FWA) detection requires machine learning models that detect anomalous billing patterns while maintaining low false positive rates that would disrupt legitimate provider relationships. Both require engineering sophistication that most claims system vendors have not invested in.
We build claims processing systems and modernize legacy claims platforms for health insurance payers — implementing HIPAA-compliant claims intake and adjudication, designing COB workflows, building ML-based FWA detection, and meeting CMS interoperability mandates for prior authorization automation. Our teams understand the regulatory and operational complexity of claims processing and build systems that can withstand state insurance department examination.
Compliance-Native Architecture Guide
Design principles and a structured checklist for building software that is compliant by default — not compliant by retrofit. Covers data architecture, access controls, audit trails, and vendor due diligence.