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HEALTHCARE CLAIMS

Healthcare claims, end-to-end, in hours instead of weeks.

From EDI intake to a ready-to-send EOB, SmartClaim runs every claim through a six-stage AI pipeline clearing backlogs, catching fraud, and reserving human review for the claims that actually need it.
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Healthcare Claims

The Problem We Solve

Traditional EDI environments can be difficult to manage as transaction volumes, trading-partner requirements, mapping rules, and platform dependencies grow. Complex data conversion across EDI, XML, APIs, and SQL systems often creates batch-processing delays, mapping errors, duplicate claims, missed transactions, inconsistent data, and limited visibility into fraud or billing issues.

These challenges become harder to control when claims move across multiple servers, legacy interfaces, clearinghouses, payer systems, and downstream billing platforms. Manual reconciliation and delayed batch processing make it difficult for operations teams to identify bad data, duplicate activity, conversion failures, or suspicious claims before they affect payment and reporting.

SmartClaim simplifies this complexity with AI-powered, real-time claims processing and data transformation. The platform helps automate EDI intake, mapping, validation, duplicate detection, fraud screening, code and eligibility checks, and conversion from EDI to XML, JSON, or SQL-ready data. Real-time processing and actionable analytics give teams immediate visibility into exceptions, claim status, data quality, and operational trends—making claims processing, billing integration, and downstream transmission faster, more accurate, and easier to manage.

Who Gets the Most Out of It

# Claims Operations
Reduce claim backlogs with real-time intake, validation, exception routing, and workflow visibility from submission through resolution.
# EDI & Integration
Simplify EDI mapping, transformation, and conversion across X12, XML, JSON, APIs, and SQL-based downstream systems.
# Payment Integrity
Identify duplicate, suspicious, and inconsistent claims earlier using AI-assisted validation, fraud screening, and actionable exception analytics.
# Billing & Reimbursement
Improve billing accuracy with validated claim data, pricing logic, payment status visibility, and cleaner downstream reimbursement workflows.

Hover any highlighted avatar to see what they get out of it

# Claims Operations
Reduce claim backlogs with real-time intake, validation, exception routing, and workflow visibility from submission through resolution.
# EDI & Integration
Simplify EDI mapping, transformation, and conversion across X12, XML, JSON, APIs, and SQL-based downstream systems.
# Payment Integrity
Identify duplicate, suspicious, and inconsistent claims earlier using AI-assisted validation, fraud screening, and actionable exception analytics.
# Billing & Reimbursement
Improve billing accuracy with validated claim data, pricing logic, payment status visibility, and cleaner downstream reimbursement workflows.

Outcomes Our Customers See

Claims Processing
0 %

Claims move through validation, routing, and exception handling without batch delays.

Automated

Data Validation

SmartClaim detects mapping errors, duplicates, and incomplete claims before downstream processing.

AI-Assisted

Fraud Detection

AI flags suspicious patterns, duplicate billing, and anomalies for focused investigation.

End-to-End

Claims Visibility

Teams track claim status, exceptions, transformations, and resolution across connected systems.

How It Works

Claims Ingested Directly from EDI Six-Stage AI Validation on Every Claim Fraud and Errors Detected Before Payment EOBs Generated Automatically
Claims Ingested Directly from EDI
SmartClaim receives healthcare claims directly from EDI transactions and converts them into structured, validation-ready data without relying on slow batch handoffs.
Six-Stage AI Validation on Every Claim
Each claim passes through eligibility checks, code validation, fraud screening, duplicate detection, payer-specific rules, and contracted pricing before moving forward.
Fraud and Errors Detected Before Payment
AI-assisted controls identify suspicious billing, duplicate claims, coding issues, and data inconsistencies early—before they create payment, reconciliation, or compliance problems.
EOBs Generated Automatically
Once a claim is validated and resolved, SmartClaim generates the Explanation of Benefits automatically, reducing manual drafting and accelerating downstream billing and payment workflows.

Why SmartClaim

Most claims platforms speed up single stage eligibility checks, or fraud scoring, or pricing lookups and leave the rest of the pipeline as manual handoffs. SmartClaim runs all six stages as one automated flow, so a claim doesn’t just move faster through any one step it moves from intake to a finished EOB without waiting on a human at all, unless it genuinely needs one.

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Common Questions

FAQs

What is SmartClaim and how does it use Sequora Agentic AI?

SmartClaim is an AI-powered healthcare claims platform that uses Sequora’s agent orchestration to automate claim intake, validation, fraud checks, duplicate detection, rule processing, pricing, and exception routing across connected systems.

Stop letting backlogs and billing errors eat your margin.

See how SmartClaim resolves claims in hours, catches fraud before payment goes out, and keeps providers paid on time.

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