Capabilities

Everything Claimaro actually does.

This is the full inventory, written for evaluation rather than persuasion — organized so you can find a specific capability fast. For the shorter version with screenshots, see the platform tour.

Claims

Claims & adjudication

The engine that decides what a claim pays, and the workflow around the claims it cannot decide alone.

  • Auto-adjudication with priority-ordered rule evaluation
  • Claims queue with configurable review routing
  • Line-level adjudication on every claim
  • Appeals workflow with per-claim appeal history
  • Automatic repricing against contracts and fee schedules
  • Plain-language rationale on every EOB
  • Bulk claim import
  • Complete audit trail on every claim action
Plan configuration

Plan & benefit design

Configure how a plan pays without writing code — and test a rule against a real claim before it goes live.

  • Rule editor with plain-English rendering of every condition
  • Rule tester — evaluate a rule against a claim before publishing it
  • Priority ordering and conditional logic
  • Benefit designs with recent-change history
  • Diagnosis buckets for grouping conditions
  • Accumulators — deductible, out-of-pocket, sharing limits
  • Family accumulators with per-member rollup
  • Coordination of benefits
  • Copay structures and cost-sharing calculation
Pricing

Pricing, fee schedules & contracts

What a service costs, where that number comes from, and who negotiated it.

  • Fee schedules with effective dating
  • CPT procedure code directory
  • ICD-10 diagnosis code directory
  • J-code / HCPCS Level II directory
  • Provider contracts with automatic contract resolution
  • Tenant-specific rate overlays
  • CMS clinical edits
  • Shadow-compare — run edits in observation mode before enforcing them
  • PBM eligibility feeds and pharmacy adapters
Interoperability

Clearinghouse & EDI

Native X12 across the transaction sets a health plan actually runs on — not a bolt-on integration.

X12 transaction sets

  • 837 — professional and institutional claims
  • 835 — electronic remittance advice
  • 270 / 271 — eligibility inquiry and response
  • 276 / 277 — claim status inquiry and response
  • 277CA — claim acknowledgement
  • 278 — authorization request and response
  • 820 — premium payment
  • 999 — functional acknowledgement

Clearinghouse connections

  • Availity
  • Change Healthcare
  • SDS
  • Generic adapter for any partner

Transports

  • AS2
  • SFTP
  • REST / HTTPS
  • SMTP

Operations

  • Inbox and outbox with per-transaction status
  • Authorization tracking
  • Realtime transaction log
  • Per-tenant clearinghouse partner configuration
Membership

Members & enrollment

From a prospect filling out a form to a member with an ID card, without leaving the platform.

  • Drag-and-drop enrollment form builder
  • Multi-step enrollment with plan and tier selection
  • Enrollment review and approval workflow
  • Public enrollment funnels with per-tenant branding
  • Public rate estimator as an enrollment step
  • Member import and bulk actions
  • Household and dependent management
  • ID card generation
  • Member status lifecycle tracking
  • Document collection and verification
Architecture

Four surfaces, one system

Everyone who touches a claim gets their own branded surface — all reading and writing the same data, with no sync job in between.

Member portal

  • Plan details and coverage
  • Claim submission
  • Digital ID card
  • Documents
  • Household and dependents
  • Facility search
  • Notifications and account settings

Provider portal

  • Claim submission and status
  • Eligibility verification
  • Authorization requests
  • Remittance advice
  • Document exchange and secure messaging
  • Provider onboarding
  • Provider-side user management

Partner portal

  • Lead tracking
  • Member roster
  • Earnings and commission statements

Admin console

  • The operator workspace every other section on this page describes
Money

Payments, finance & billing

Money in from members, money out to providers, and a ledger that reconciles both.

  • Double-entry fund ledger
  • Provider and member disbursement
  • Recurring member billing
  • Payroll with tax engine
  • Finance health gauges
  • Payment gateways — Stripe, NMI, Authorize.net, and manual entry
  • Bank connectivity via Plaid
  • QuickBooks export
Growth

CRM, marketing & growth

The person enrolling today is the member filing a claim tomorrow. Both live in the same system.

  • CRM with a unified activity timeline per contact
  • Sales pipelines with stage management
  • Saved smart lists and segmentation
  • Lead scoring
  • Automations — event triggers, branching graphs, dry-run simulation
  • Email and SMS campaigns
  • Funnel builder
  • Form builder
  • Ad platform connections
  • Media library
  • Folder organization across messaging and marketing
Analytics

Reporting & analytics

Answers for the board deck, on a schedule, without an analyst.

  • Report engine with saved report definitions
  • Scheduled report runs with delivery
  • Report decks exported to PowerPoint
  • Operational dashboards
  • Claims, member, and enrollment report sets
  • Actuarial workbench
  • Forecasting engine
  • CSV export
Compliance

Compliance & governance

The filings you owe the IRS and the controls an auditor asks for.

ACA reporting

  • Forms 1094-B and 1094-C
  • Forms 1095-B and 1095-C
  • Coverage-month calculation
  • Employer group tracking
  • SSN and employee-year import

Privacy, security & governance

  • HIPAA field masking
  • PII handling controls
  • System-wide audit log
  • Row-level-security tenant isolation
  • Role-based permissions
  • E-signature with signing certificates
Infrastructure

Platform & administration

What makes one deployment serve many organizations, each looking like its own product.

  • Row-level-security tenant isolation
  • Per-tenant terminology overrides
  • Custom branding and domains
  • Integrations — QuickBooks, Twilio, SendGrid, Stripe, Plaid, Zapier
  • Notification delivery across email, SMS, and portal
  • Knowledge base
  • Facility network management
  • Public find-care search
  • Member concierge
In development

Plan builder & multi-path rating engine

Not shipped yet — listed here because it is where the platform is going, and because it is the part of the roadmap buyers ask about most. No dates, and nothing below is available today.

Cross-funding comparison

One census priced across multiple funding models — healthshare, level-funded, self-funded, ICHRA — in a single session, on a normalized total-cost basis.

Rating and adjudication in one engine

Plan designs priced by re-adjudicating a reference claims set through the same engine that pays real claims. The quote and the payment share one source of truth.

Want to see any of this running?

A 30-minute walkthrough against a plan modeled on yours beats any feature list — including this one.

Book a demo Platform tour