Adjudicaro reads your 837s, applies your plan rules, and recommends a decision for every line, with the reason in plain English. Your adjusters make the call. Your claims system stays the system of record.
Prior authorization PA-55102 is on the claim. The member reaches the $6,000.00 out-of-pocket maximum on this line, so their coinsurance is capped at $180.00 and the plan pays the rest.Plan §4.4
3 units were billed, but the medically unlikely edit allows 2 per day. 2 units are priced and the third is denied.MUE 20610 = 2CO-151
We receive copies of your claims and files and hand decisions back. Your providers and your clearinghouse never notice a difference.
Approve, deny or pend for every service line, with the allowed amount, plan share, member share and standard adjustment codes.
Every line explains itself, and every sentence points to the plan provision, coding edit or fee schedule behind it.
CMS bundling and unit-limit edits run on every claim, alongside eligibility, timely filing, exclusions and prior authorization.
Claims for the same member run in date order, so deductible and out-of-pocket amounts carry from claim to claim.
Accept with one click or override with a required reason. Every action lands in an audit log you can hand to an auditor.
Decisions export as a CSV or a balanced draft 835 that loads into the claims system you already run.
The rules decide every dollar. Your people decide every claim.
Adjudicaro never pays a claim and never contacts a provider. It recommends; your claims system pays.
The rules engine sets every amount and code. AI only rewords an explanation, and a checker rejects anything the rules didn't produce.
We sign a BAA with you, and every action is logged.
Adjudicaro is built on the same engine as Claimaro for TPAs. Start with recommendations beside your current system, and move to the full platform when you're ready.
Adjusters work the queue all day. Managers review overrides and answer appeals with the reason already written.
Book a walkthrough, then send us a sample file. We'll show you Adjudicaro's recommendations next to the decisions your adjusters made.