Claim Adjudication Automation

Mindbowser’s Claim Adjudication Automation Implementation Service enables payers and insurers to accelerate claim decisioning by combining AI/ML models and rule-based processing on AWS. Our engineering and domain teams work closely with your claims operations, compliance, and IT stakeholders to architect, develop, and implement automation frameworks that optimize claim evaluation, reduce manual review, and ensure adherence to payer regulations.

Engagement Scope:

1. Discovery & Architecture Design: Analyze existing claim workflows and define decisioning logic, data flows, and KPIs.
2. AWS Environment Configuration: Deploy secure infrastructure using AWS Lambda, S3, API Gateway, CloudWatch, and SageMaker.
3. Rules & ML Model Development: Implement configurable rules and machine learning models for auto-adjudication, exception handling, and fraud flagging.
4. Data Validation & System Integration: Enable interoperability through EDI, FHIR, or API-based integration with core payer systems.
5. Testing & Optimization: Validate rule performance, model accuracy, and compliance readiness before go-live.
6. Documentation & Enablement: Provide technical documentation, dashboards, and team enablement for ongoing operations.

Deliverables Include:

1. AWS-based adjudication architecture and configuration guide
2. Deployed automation workflows and API integrations
3. Rule libraries and ML model configurations
4. Compliance and audit logging setup

Final performance and accuracy validation report With Claim Adjudication Automation, payer organizations streamline claims processing, improve operational efficiency, and enhance accuracy — all while maintaining security, scalability, and traceability on AWS.