Kaia Claims
Claims intelligence that learns from every adjudication.
Kaia Claims processes healthcare payer claims with AI-powered adjudication, learning from every human decision to deliver measurably better accuracy, fraud detection, and straight-through processing — end-to-end from claim submission through appeals.
Built for Your Role
What Kaia Claims does for you.
Every role gets a purpose-built operating surface. Not a generic dashboard — a workspace designed for how you actually work in Claims.
AI triages 90% of routine claims so you focus on exceptions
Adjudicate flagged claims with full context. SIU referrals are pre-scored for risk.
AI triages 90% of routine claims so you focus on exceptions
Adjudicate flagged claims with full context. SIU referrals are pre-scored for risk.
Increase straight-through processing from 7% to 42%
Real-time visibility into claim triage, STP rates, and fraud detection across all lines.
State-by-state regulatory compliance with automated audit trails
NAIC and SOX compliance monitoring. Every claim decision is documented and defensible.
After signup, you choose your role and land directly in your Kaia Claims workspace.
Full Lifecycle
Every stage of claims processing, powered by intelligence.
Submission
Claims intake, eligibility verification, and documentation completeness.
Adjudication
AI-powered risk assessment, benefit determination, and auto-adjudication.
Payment
Payment calculation, provider reimbursement, and EOB generation.
Appeals
Appeal intake, clinical review, and determination tracking.
FWA Detection
Fraud, waste, and abuse pattern detection across claims history.
Risk Classification
Four risk tiers. One confidence score. Full reasoning.
Complex claims with potential fraud indicators, high-value settlements, or litigation triggers requiring senior adjuster review.
Standard claims with some complexity — multi-party involvement, prior claim history, or ambiguous coverage.
Straightforward claims with clear coverage, complete documentation, and established precedent for automated processing.
Claims with regulatory reporting requirements, compliance triggers, or patterns matching known fraud typologies.
The Learning Loop
Every correction makes the system smarter.
AI Assesses
Submit a claim. The Intelligence Engine analyzes documentation, coverage, history, and risk factors with confidence-scored assessments.
Adjuster Reviews
Claims adjusters review AI assessments. When the model gets it wrong, they correct it — adding underwriting context the AI missed.
System Learns
Each correction creates a training data pair routed to the right learning layer. The model improves on claims-specific patterns every month.
Capabilities
Built for the full claims lifecycle.
Claims Processing
End-to-end claims intake, assessment, and routing. AI handles the routine, humans handle the complex.
Underwriting Intelligence
Risk scoring informed by historical patterns. Every assessment makes the model smarter.
Fraud Detection
Pattern recognition across claims history. Catches anomalies humans miss.
$30B
Insurtech Market
Global insurtech market size, growing 40%+ annually with AI-driven claims processing leading adoption.
0.85
Confidence Threshold
Minimum confidence score for automated claim routing. Below threshold triggers human adjuster review.
State Regs
Compliant
Built for state-by-state regulatory compliance. Full audit trails, explainable decisions, fair claims practices.
Intelligence Engine
Every adjuster correction flows through the five-layer continuous learning system — from prompt fixes ($0.03, instant) to architecture evolution (monthly, human-required). The triage system routes each correction to the right learning mechanism automatically.
See the full Intelligence Engine architecture →Claims Differentiator
Multi-jurisdiction complexity.
Insurance and financial services operate across 50+ regulatory jurisdictions. Kaia Claims handles state-by-state variation natively — not as an afterthought.
50+
State Regulations
Every state has distinct fair claims practices, reporting requirements, and compliance rules. The Intelligence Engine encodes jurisdiction-specific logic.
Claims Lifecycle
End-to-end intelligence across intake, assessment, routing, fraud detection, and resolution. Each stage feeds the learning loop.
SIU Integration
Special Investigations Unit workflows built in. Flagged claims route to SIU with full pattern analysis, typology matching, and audit trails.
Same Intelligence Engine · 8 Regulated Industries
See claims intelligence in action.
Submit a claim. Review the AI assessment. Watch the learning loop improve in real time.
Kaia Claims Workflow
6-Stage Industry Process
Only claims platform publishing straight-through processing rate trending (7% to 50%+), fraud detection precision, and turnaround time benchmarks. Shift Technology keeps fraud accuracy secret. Every adjuster correction improves the model for all payers.
Claim Intake
FNOL processing, EDI 837 ingestion, document OCR, initial data extraction and validation
HIPAA — EDI transaction set standards (X12 837/835)
Adjudication
AI risk scoring, coverage verification, STP routing, complexity triage, auto-adjudication for high-confidence claims
CMS — timely filing and clean claim requirements
Payment & Settlement
EDI 835 remittance, provider payment calculation, member cost-sharing, EOB generation
Prompt Payment Laws — state-specific payment timelines
FWA Detection
Fraud, waste, and abuse pattern detection, provider network analysis, outlier identification
CMS — False Claims Act compliance
Appeals & Review
Member and provider appeals processing, peer review routing, overturn analysis
NAIC Model Bulletin — appeals process requirements
Compliance & Reporting
Regulatory reporting, audit trail generation, STP trending, model performance tracking
SOX — financial reporting controls
Transparent Benchmark
Straight-Through Processing Rate
Target: 50% | Industry average: 7%
No competitor in Claims publishes this data.