Kaia Claims
Claims intelligence that learns from every adjudication.
Kaia Claims runs healthcare payer claim traffic as a governed operating loop: pre-trained process intelligence prepares evidence, routes exceptions, detects FWA signals, and learns from authorized corrections — designed to measurably improve accuracy every month through governed correction learning — while accountable claims teams retain final coverage, payment, and appeal authority.
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.
Raise first-pass adjudication accuracy with rule-cited rationale
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 checks, STP eligibility, and human-owned adjudication readiness.
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.
High-dollar, out-of-network, prior-authorization, medical-necessity, or coding evidence requires senior payer review.
Standard payer claims with coverage questions, provider credential flags, coding ambiguity, or missing medical documentation.
Clean EDI 837 claim, verified eligibility, in-network provider, complete coding, and STP-ready benefit checks.
Duplicate, upcoding, unbundling, phantom billing, appeal sensitivity, or network FWA signal requiring SIU referral.
The Learning Loop
Every correction makes the system smarter.
AI Prepares
Submit an EDI 837 or claim packet. Kaia checks eligibility, policy terms, CPT/ICD-10/HCPCS evidence, medical necessity, duplicate risk, and FWA signals.
Payer Team Acts
Claims, coding, payment, appeals, and SIU teams review the exact evidence, validate the action, and decide the authorized payer outcome.
System Learns
Each correction becomes a governed signal routed to the right learning layer. The model improves on claims-specific patterns every month.
Capabilities
Built for the full claims lifecycle.
Claims Processing
EDI 837 intake, eligibility, medical coding, STP readiness, FWA referral, payment, and appeals routing.
Adjudication Intelligence
Benefit-plan, medical-necessity, CPT/ICD-10/HCPCS, fee schedule, and coverage evidence packaged for payer teams.
Fraud Detection
Provider, member, coding, duplicate, and network anomalies routed to SIU with reviewer-ready evidence.
90%+
First-Pass Accuracy · target
Rule-cited first-pass adjudication accuracy against the published gold-set — a Day-0 target, published monthly as measured.
85%+
FWA / SIU Precision · target
Fraud, waste, and abuse separated from clean claim traffic with auditable evidence — Day-0 gold-set target, published monthly.
<5%
False-Positive Rate · target
Clean claims incorrectly flagged, held low so good claims are never blocked — Day-0 gold-set target, published monthly.
Intelligence Engine
Every authorized claims correction flows through the five-layer continuous learning system: prompt fixes, rule updates, knowledge improvements, model adaptation, and architecture feedback. The triage system routes each correction to the right learning mechanism automatically.
See the full Intelligence Engine architecture →Claims Differentiator
Healthcare payer complexity.
Healthcare payer claims combine EDI, coding, benefits, medical necessity, provider behavior, appeals, CMS/state requirements, and SIU processes. Kaia turns that into one operating loop.
Codes
Medical Coding Evidence
CPT, ICD-10, HCPCS, modifier, diagnosis, and procedure evidence stays attached to the claim action.
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 processes built in. Flagged claims route to SIU with full pattern analysis, typology matching, and audit trails.
Same Intelligence Engine · Every Kaia Product
See claims intelligence in action.
Run a payer claim packet. Review the evidence and action. Watch STP, FWA, appeal, and benchmark posture update in real time.
Kaia Claims Process
6-Stage Industry Process
Claims operating platform designed to publish status-labeled straight-through processing, fraud precision, and turnaround benchmark posture after production baselining. No incumbent publishes fraud accuracy; Kaia publishes it monthly. Every governed adjuster correction improves tenant-scoped routing and benchmark readiness without making the final claim decision.
Kaia runs process preparation, routing, evidence assembly, and correction learning; authorized humans retain final regulated authority.
Claim Submission & Intake
Claim submission, EDI 837 ingestion, document OCR, initial data extraction and validation
HIPAA — EDI transaction set standards (X12 837/835)
Triage & Assignment
AI risk scoring, coverage verification, STP eligibility routing, complexity triage, and human-owned adjudication readiness
CMS — timely filing and clean claim requirements
Investigation & Documentation
Document gathering, provider verification, duplicate checks, and the continuous fraud/waste/abuse band — pattern detection, provider network analysis, outlier identification
CMS — False Claims Act compliance
Adjudication
Coverage determination, benefit calculation, medical necessity, and human review
CMS — medical necessity and timely claim adjudication requirements
Settlement & Payment
EDI 835 remittance, provider payment calculation, member cost-sharing, EOB generation
Prompt Payment Laws — state-specific payment timelines
Appeals & Review
Member and provider appeals processing, peer review routing, overturn analysis, regulatory reporting, and audit-trail evidence
NAIC Model Bulletin — appeals process requirements · SOX — financial reporting controls
Target Benchmark Posture
First-Pass Adjudication Accuracy
Target: 90%
Targets presented as targets until production baselines support public RRES publication.