Claims intelligence without the compliance anxiety
Healthcare — Payers & Insurance
What the compliance landscape actually demands.
Payer technology sits at the intersection of three regulatory frameworks with different enforcement agencies, different deadlines, and different technical requirements. HIPAA governs every system processing member PHI — which is effectively every system in a payer's technology stack. CMS interoperability mandates govern every payer participating in federally regulated markets and require FHIR R4 APIs for member data access, provider directory data, and prior authorization status — with compliance deadlines that run from January 2026 forward. State insurance regulations add cybersecurity requirements through the NAIC Model Cybersecurity Law, now adopted by the majority of US states, requiring comprehensive information security programs, annual risk assessments, and 72-hour breach notification to state regulators. The prior authorization automation mandate — the most technically demanding provision of CMS-0057-F — requires payers to implement a FHIR-based prior authorization API allowing providers to submit requests and receive determinations electronically, with decision timeframes that existing manual workflows cannot satisfy. Payers without compliant FHIR implementations by 2026 face exclusion from Medicare Advantage, Medicaid managed care, and ACA marketplace participation. The technical mandate is not aspirational — it is a condition of participation in the markets that constitute the majority of payer revenue.
CMS interoperability mandates are forcing payers to FHIR-ify systems that were built on 30-year-old COBOL — and the 2026 compliance deadline is not moving.
Payer technology is dominated by legacy platforms that use AI to deny claims at scale while failing basic security audits. Cognizant's TriZetto was breached for 12 months. The industry needs engineering teams that build claims systems where compliance isn't an afterthought.
Talk to an Engineer →
First call is a senior engineer — not a sales team. We understand your regulatory environment before we write a line of code.
Start a ConversationWhere Incumbents Fall Short
The claims adjudication market is dominated by platforms that were not designed for the operational requirements they now face. FIS, Facets, and QNXT were architected for per-claim batch processing — not real-time adjudication, not FHIR-based API responses, not the transaction volumes that Medicare Advantage growth and ACA exchange enrollment have produced. Medical loss ratio requirements mean that every dollar spent on legacy system maintenance and manual workarounds is a dollar that increases the MLR, reduces the margin available for administrative investment, and ultimately constrains the plan's competitive position. Yet the switching cost for a payer to replace its core claims system is high enough that most organizations continue operating on platforms they know are inadequate rather than face the migration risk. The result is a patchwork of FHIR wrappers over COBOL cores — systems that can produce a FHIR-formatted response while the underlying adjudication logic runs on 30-year-old batch processing that cannot be examined or modified without risk to live operations. CMS auditors are beginning to examine whether FHIR implementations satisfy the interoperability requirements at a functional level — not just a syntactic one.
How We Approach Payers & Insurance
The Algorithm approaches payer technology with the 2026 CMS compliance deadline as the organizing constraint, not an afterthought. FHIR R4 implementation starts with the member access API and prior authorization workflow, with every data element mapped to the underlying claims data model and every API endpoint tested against the CMS certification specifications. Claims adjudication modernization follows a strangler fig pattern — new capabilities are built on modern, cloud-native architecture that runs alongside the existing core, taking over transaction types as each migration is validated. HIPAA compliance is implemented at the architecture level: access controls, audit logging, encryption, and breach notification capabilities are infrastructure decisions made before the first line of application code is written. The NAIC cybersecurity program documentation — information security policies, risk assessment evidence, vendor management records — is produced as a byproduct of the engagement, not as a separate compliance exercise. Payers that engage before the 2026 deadline have working systems. Payers that wait will be seeking emergency engineering help in a procurement environment where experienced teams are already committed.
What Success Looks Like
A successful engagement delivers a claims adjudication system that processes clean claims within CMS timelines, passes ONC certification testing for FHIR R4 interoperability, and handles prior authorization automation for the mandated procedure categories without manual intervention. The member access API satisfies CMS examination requirements at the functional level — not just syntactic compliance. Denial rates fall because the adjudication logic is accurate and documented. Days in accounts receivable decrease because provider-facing APIs surface claim status in real time. The compliance team can generate the documentation CMS examiners request without a manual evidence collection exercise. The state insurance department's cybersecurity examination finds a documented information security program with evidence packages ready for review.
Duration: 8 - 16 weeks
Output: Production system + audit documentation
A payer modernizing claims intelligence typically engages at Tier I — a focused team, tight timeline, full compliance from commit one.
What We Deploy in Payers & Insurance
Healthcare — Payers & Insurance Compliance Assessment
A structured checklist for evaluating your AI and software vendor's readiness across the key regulatory frameworks in Healthcare. Free — no email required.
Download PDF →Ready When You Are
Working in Payers & Insurance?
We've deployed teams in this environment. First call is a senior engineer.