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Healthtech · Payers & Benefits · 200–1000 · North America #b035_08

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Context

We are an employer health plan with no member cost sharing, and we run claims adjudication on a platform we built ourselves.

Industry: Healthtech · Payers & Benefits
Size: 200–1000 employees
Region: North America
Tools budget: $5K–20K per month
Needs: Claims & prior authorization. Adjudication still needs manual touches on edge cases, and we want automation that keeps payment accuracy high as volume grows.
Today: in-house platform engineers automate claim rules on a licensed core claims system · Urgency: this year
Audit evidence collection. Regulators and clients ask for proof of claims accuracy controls; assembling that evidence is slow.
Today: claims operations leaders own accuracy audits and regulator reviews using dashboards and sampling · Urgency: this year
Who decides: head of operations · security review
Expects from suppliers: Rules engines our own engineers can extend; Accuracy metrics exposed by API; Experience with self-funded and fully insured lines
Not a fit: Monolithic claims suites replacing our core; Offshore-only processing services
Stack: cloud: AWS-class hyperscaler, ticketing / issue tracker
Buying triggers: scaling transaction volume, regulatory change

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