Payers & Health Plans

Claims, Prior Authorisation & Provider Network Operations

A health plan sits between members, providers and regulators, and every one of those relationships runs on documents. Claims arrive with attachments, prior authorisations arrive with clinical notes, and provider contracts govern what may be paid for what. Scalata's agentic AI platform reads all of it against the rules that apply and leaves the reasoning on the record.

AutomatedClaim & prior authorisation intake

Rule-basedAdjudication against plan and contract terms

Same-dayTurnaround on routine determinations

DocumentedClinical rationale on every decision

How it works

The four-step journey

The same shape every time: name what is going wrong, put the documents somewhere they can be read, let people ask questions of them, and then hand the repeating parts to agents that do not need asking.

01
Confronting Determination Volume & Turnaround Rules
Claims and authorisation requests arrive faster than they can be read, each governed by plan terms, provider contracts and regulatory turnaround limits. Manual review creates backlogs, and inconsistent determinations create appeals.
High determination volumeManual clinical reviewRegulatory turnaround limitsAppeal-driving inconsistency
02
Building a Unified Payer Data Core
Claims, clinical attachments, plan documents and provider contracts are ingested and joined, so a determination can be reasoned about against everything that governs it.
Document AIClaim & attachment extractionPlan document parsingProvider contract terms
03
Activating Intelligent Determination Analytics
Requests are tested against benefit terms, medical policy and the contract in force, with comparable prior determinations surfaced so like cases are decided alike.
Conversational AIBenefit & medical policy checksContract term applicationPrior determination comparison
04
Full Automation with Proactive Payer AI Agents
Routine determinations complete within the turnaround limit, complex ones reach a clinician already assembled, and agents monitor the queue for cases approaching a regulatory deadline.
Straight-through determinationsClinician review packsTurnaround deadline monitoringAppeal preparationAI Agents

Strategic Outcome

Determinations are made against the terms that actually apply, within the time the regulator allows, and with the rationale recorded. Appeals fall because like cases are decided alike, and clinical reviewers spend their time on the cases that need a clinician.

Who Scalata serves