Process clinical claims faster, with documentation that stands up to audit.
Nexoraa orchestrates intake, documentation review, coverage validation, medical necessity assessment, and adjudication recommendation - keeping every clinical and policy decision evidenced, sourced, and reviewable.
Why claims processing is operationally and clinically hard
Claims processing combines unstructured clinical documentation, complex coverage rules, mandated turnaround times, and severe consequences for getting decisions wrong. The right answer is governed agentic execution with clinical reviewers in the loop where it matters.
The recurring failure points.
Documentation heterogeneity
Clinical notes, lab results, imaging reports, and prior auth letters arrive in different formats, often handwritten or scanned.
Coverage complexity
Plan documents, riders, exclusions, network rules, and formulary tiers are dense and plan-specific.
Medical necessity judgment
Necessity is clinical judgment grounded in evidence, guidelines, and member context.
Turnaround time pressure
Regulated windows mean missed deadlines trigger penalties and member harm.
Explainability requirements
Members and regulators require explanations that cite the specific evidence used.
How Nexoraa executes this workflow.
Nexoraa breaks the claim journey into specialised agents. Clinical judgment remains with the reviewer; the platform handles intake, extraction, retrieval, validation, and evidence assembly.
Intake Agent
Accepts claims via API, EDI, fax-to-PDF, or member portal upload. Detects format, classifies claim type, and extracts identifiers.
Document Extraction Agent
OCR and intelligent extraction convert clinical documents into validated JSON.
Eligibility & Coverage Agent
Retrieves the member's plan, applies network rules, and identifies coverage flags.
Medical Necessity Retrieval Agent
Retrieves clinical guidelines, prior authorisation requirements, and member history.
Adjudication Recommender
Synthesises eligibility, coverage, and necessity context into a cited recommendation.
Haluvance Validation
Validates grounding, schema, and policy confidence before reviewer routing.
Clinical Reviewer Routing
Routes clinical-judgement cases with evidence packs; reviewers accept, modify, or override.
Notification & Posting Agent
Generates member notification, posts adjudication, and writes the audit record.
Where this workflow plugs in.
Claims platforms, member portals, EDI gateways, document management, clinical knowledge bases, and case management systems. Private cloud or on-premise deployment keeps PHI inside the customer boundary where required.
Outcomes our customers measure.
Reviewer throughput
Reviewers handle more cases because evidence is pre-assembled and cited.
Turnaround time
Mean time to adjudication drops; regulated windows are met more reliably.
Explanation quality
Member notifications cite specific clinical and plan evidence.
Audit defensibility
Every recommendation, override, and decision has a stored rationale and source citation.
Clinician satisfaction
Reviewers spend time on judgment, not chart hunting.
How Nexoraa governs this workflow.
Nexoraa supports private deployment with no PHI egress, role-based access aligned to clinical roles, document-level retrieval access control, immutable audit logs, and Haluvance-enforced grounding.
Why Nexoraa for this workflow.
Private deployment
PHI processing stays inside the customer environment with in-region endpoints or self-hosted models.
Document-level access control
A reviewer never sees a case they are not assigned to, even at retrieval time.
Grounded recommendations
Haluvance blocks adjudication outputs that do not cite clinical and plan evidence.
Override transparency
Clinician overrides are logged with reasons and become training feedback.
Keep exploring this operating path.
Related solution domain
Read about the broader operations area that contains this workflow.
Haluvance
Go deeper on runtime enforcement: contracts, gateway, decisions, and proof.
Multi-Agent Orchestration
See the platform capability that coordinates specialist agents end to end.
See this workflow run on your data shape.
Bring a sample dataset under NDA. We will demonstrate the workflow on it.