Professional and institutional claims normalized via FHIR Claim / X12-equivalent payloads. Facility-side tie-outs:
hospital finance
. Exceptions propagate to
claims tracking
.
Coding holds: 842
Fraud queue: 39
Auto-paid batch nightly
Manual adjudication (demo)
Claim ID
Decision
Approve full
Partial pay
Deny — medical necessity
Deny — duplicate
Pend — info request
Paid amount (KES)
Adjuster narrative
Post adjudication
Route to peer review
Clinical attachment:
SOAP notes
/
coded problems
.
Dashboard
Claim
Type
Billed
Queue
CLM-884021
Inst — IP
KES 186,400
Coding
CLM-884018
Prof — OP
KES 6,200
Ready pay