Everything Claimaro actually does.

The engine

• Auto-adjudication with priority-ordered rule evaluation
• Line-level adjudication on every claim
• Automatic repricing against contracts and fee schedules
• Duplicate claim detection routed to review
• Auto-approve and high-dollar review thresholds
• Auto-approve limits by procedure code, on the billed or allowed amount, with an optional claim total capEarly access
• Plain-language rationale on denied and edited lines
• Standard denial reason codes on denied lines

Review workflow

• Claims queue with configurable review routing
• Reviewer assignment with a workload view
• Pended claims with follow-up dates and overdue flags
• Blocked queue for claims the engine could not finish
• Facility (UB-04) claims priced line by line by a reviewer
• Appeals workflow with per-claim appeal history
• Claim reopen with a recorded reason
• Audit trail on claim actions

Claim intake

• Bulk claim import
• Claimaro AI reads an uploaded bill into a new claimEarly access
• Multiple service dates on one claim
• Staff file attachments on claims, one at a time or in bulk
• Drug NDC, quantity, and unit on claim lines
• Add or correct the NDC on a saved claim
• Member reimbursement when the member paid up front

Member communication

• EOB or EOS builder with your wording and branding
• EOB or EOS as a PDF that members view and download in the portal
• Claim decision notices by portal, email, and SMS

• Rule editor with plain-English rendering of every condition
• Rule tester: evaluate rules against a sample claim
• Priority ordering and conditional logic
• Benefit designs by plan and tier, with change history
• Diagnosis buckets for grouping conditions
• Accumulators: deductible, out-of-pocket, sharing limits
• Family accumulators with per-member rollup
• Annual benefit maximums
• Pre-existing condition waiting periods by plan
• Exclusion lists for tobacco and cosmetic procedures
• Coordination of benefits
• Copay structures and cost-sharing calculation
• Claims paid under the plan in force on the date of service
• Per-benefit status shown to members: Sharable, Discount, Included, Not sharable, or hidden
• Member-facing benefit status labels in your own wording
• Unshared amount applied once a year or once per incident, with incident limitsEarly access
• Claims grouped into incidents by diagnosis automatically, and staff can move a claim to another incidentEarly access
• Incident balances on the member record and in the member portal, in your own wordingEarly access

Fee schedules

• Fee schedules with effective dating
• Reference-based pricing at a set percent of Medicare
• CMS ASP drug rates, loaded quarterly in one click
• CMS DMEPOS fee schedule, loaded by state
• CMS ambulance fee schedule rates by pickup ZIP
• Per-unit pricing for drugs and ambulance mileage
• Modifier-aware DME pricing: rental, purchase, used
• Multi-state DME pricing at the member's home state
• CMS rate loads never overwrite your own rates

Contracts

• Provider contracts with automatic contract resolution
• Contract rates: percent of Medicare, per diem, case rate, flat
• Negotiated rate overlays on top of your base schedule
• Contract what-if: reprice past claims under a contract

Code directories

• CPT procedure code directory
• ICD-10 diagnosis code directory
• HCPCS Level II directory from the CMS quarterly release

CMS clinical edits

• NCCI procedure-to-procedure bundling edits
• CMS MUE unit limits: practitioner, DME, and outpatient
• Your own unit limits on top of the CMS limits
• Drug wastage modifier checks (JW and JZ)
• Ambulance origin and destination modifier check
• Edit hits route to review with the CMS reason, never auto-deny

X12 transaction sets

• 837: professional and institutional claims
• 835: electronic remittance advice
• 834: benefit enrollment, inbound and outbound
• 270 / 271: eligibility inquiry and response
• 277CA: claim acknowledgement
• 278: authorization request and response
• 999 and TA1: acknowledgements

Enrollment feeds (834)

• 834 files by SFTP, upload, or API
• A 999 back to the sender for every file
• Per-sender plan code maps and employer groups
• File review: applied, exceptions, rejected, skipped
• Exceptions queue: map codes, link or create members
• Truncated full files held before they apply
• Retro terminations flag paid claims for recovery
• Waiting claims re-run when the member arrives
• Outbound 834 to carriers, PBMs, and vendors
• Change files, full files, or both, on a schedule
• Email alerts for exceptions and failed sends

Clearinghouse connections

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

Transports

• AS2 outbound: signed and encrypted, with signed receipts
• SFTP
• REST / HTTPS
• SMTP

Operations

• Inbox and outbox with per-transaction status
• Authorization tracking
• Realtime transaction log
• Per-tenant clearinghouse partner configuration
• Editable partner connections with write-only passwords
• Drug NDC read from incoming 837 claims
• Two clearinghouses on one account, each connection with its own payer ID

• Drag-and-drop enrollment form builder
• Multi-step enrollment with plan and tier selection
• Save and resume an application by application ID
• 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
• Coverage history timeline on every member
• Branded ID card designer
• Staff download of any member's ID card
• Member status lifecycle tracking
• Document collection
• Member newsletter editor with portal notifications
• Membership-number counter that never reuses a retired number
• Staff can correct a member's number

Member portal

• Plan details and coverage
• Claim submission, with bill upload
• Claim status, benefit statements, and appeals
• Digital ID card: save as PDF or image, or print
• Documents, program documents, and member forms
• Household and dependents
• Facility search
• Dues payments and saved cards
• Help requests and replies
• Newsletter
• Notifications and account settings
• Theme, pages, and navigation you control

Provider portal

• Claim submission and status
• Batch 837 claim upload
• Eligibility verification
• Authorization requests
• Remittance advice
• Appeals on denied claims
• Document exchange and secure messaging
• Provider onboarding: self sign-up or invitation
• Provider-side user management

Partner portal

• Lead tracking
• Personal tracking link and referral form
• Member roster
• Shared marketing collateral
• Agreements, tax forms, and licenses
• Earnings, commission statements, and payout history
• Passwordless sign-in

Admin console

• The operator workspace every other section on this page describes
• View as a member, provider, or partner
• Staff with custom roles can sign in as a member or provider to help them

Working tickets

• Log a contact from any screen
• Ticket list with filters, filter counts, and shared saved views
• Numbered pages of 20, 50, or 100 tickets
• Ticket list export to CSV
• Ticket panels on member, claim, provider, and enrollment records
• Full contact history per member, with CSV export
• Bulk assign, close, status, and priority changes
• Merge duplicate tickets
• Reply and note templates

Routing and service levels

• Queues with round-robin or least-loaded assignment
• Assignment rules by category, channel, caller, and priority
• Business-hours due dates that skip holidays
• Overdue alerts and automatic closing
• Custom categories, statuses, and fields

Channels

• Member portal help requests with replies
• Provider portal messages open tickets
• Inbound calls ring staff in the browser
• Log a call as a ticket when it ends
• Inbound texts open or update tickets

Automation and reporting

• Ticket triggers and actions in automations
• Ticket reports with charts and scheduled delivery
• Team metrics: open load, first response, first-contact resolution

Paying claims

• Claim payment batches with optional two-person release
• Provider and member payment runs and payment files
• Six payment methods: check, ACH, virtual card, wire, card, other
• Automatic check numbering
• Check clearing by hand or from your bank's file
• Outstanding and stale check tracking with stop and reissue
• Positive pay files for your bank
• Refunds, returns, reissues, stops, and voids
• Payment register search by check, claim, payee, or member
• Payment status shown to members and providers
• One Payouts tab for claim payouts, funding, and payments
• Branded payment emails with a member-portal sign-in button
• Prompt-pay tracking with a late-payment interest report

Member billing

• Recurring member billing
• Payment gateways: Stripe, NMI, Authorize.net, and manual entry
• Staff charges to a card on file
• Grace period: suspend, then terminate for non-payment
• Late-added coverage billed automatically

Stop-loss (self-funded plans)

• Specific and aggregate policies with lasers
• Attachment tracking against paid claims
• Threshold and trigger-diagnosis alerts
• Carrier notices as CSV and PDF
• Reimbursement filings tracked to payment
• Monthly census for aggregate factors

Accounting and tax

• Finance health gauges
• Financial overview: revenue, expenses, cash flow
• Period summary: revenue, claims paid, loss ratio
• Outstanding liability sheet with aging bands and quick date picks
• Check register exports
• 1099-MISC report for providers
• QuickBooks sync: claims, payments, dues, and invoices
• Books: a double-entry general ledger inside Financials, included at no extra chargeEarly access
• Claim payments, dues, and commissions post to your books as they happen, with receivables and payablesEarly access
• Bank reconciliation and period close, with P&L, balance sheet, and cash flowEarly access
• Invoices and forms, online invoice payment, statements, and remindersEarly access
• Payroll and 1099sEarly access
• QuickBooks sync keeps working alongside BooksEarly access

• CRM with a unified activity timeline per contact
• Sales pipelines with stage management
• Saved smart lists and segmentation
• Lead scoring
• Leads API: send leads in from Zapier or your own code
• Automations: event triggers, branching graphs, dry-run simulation
• Email and SMS campaigns
• Email and SMS drip sequences
• Email and SMS template libraries
• Multi-step funnel builder with lead capture
• Form builder
• Referral partners: attribution, commissions, and payouts
• Ad platform connections
• Media library
• Folder organization across messaging and marketing
• Website builder with visitors, opt-ins, sources, and devices per siteEarly access
• Surveys with branching and scored quizzes, with lead captureEarly access
• Funnel analytics: visitors, opt-ins, and enrollments per funnelEarly access
• Conversations inbox: one text and email thread that follows a lead into membershipEarly access

• Report engine with saved report definitions
• Report datasets: claims, members, enrollment, payments, providers, leads
• Starter report templates
• Scheduled reports by email, daily to quarterly
• Report decks exported to PowerPoint or PDF
• Operational dashboards
• Stop-loss large-claimant and aggregate reports
• Reports library: every built-in report in one place, including Code Analytics (top CPT and ICD-10 codes) and the liability sheet
• Share Box reports: how each claim was shared among members and who paidEarly access
• Per-claim "how this was shared" breakdown, downloadable as CSV, Excel, or PDFEarly access
• Weekly or monthly summary emails to partners and providers
• Actuarial workbench modeled on your own plans, benefit designs, and claim lag
• A claims curve built from your own members' spend (50 or more members), with specific and aggregate stop-loss priced from it, lasers included
• Reserve loadings with your measured claim lag
• Actuarial recommendations: next-year forecast, price to target, and plan design and stop-loss suggestionsEarly access
• Export to CSV, Excel, and PDF, for any date range

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
• Form PDFs and a filing-vendor Excel file

Privacy, security & governance

• Contact masking: phone and email hidden until revealed
• PII handling controls
• Automatic sign-out after inactivity
• Two-factor sign-in, required for administrators if you choose
• Eight built-in roles plus custom roles
• System-wide audit log
• Support access you control, recorded in the audit log
• Abandoned applications anonymized after 30 days

• Row-level-security tenant isolation
• Terminology that follows your model: sharing or insurance wording
• Custom branding per organization
• Your own domains for staff, member, and provider sites
• Integrations: QuickBooks, Twilio, Stripe, Zapier
• Notification delivery across email, SMS, and portal
• Automatic opt-out on bounces, complaints, and unsubscribes
• Staff sign-in with Google
• Search every record from the header
• Help Center knowledge base with an Ask AI chat
• Help Center with a step-by-step guide for every screen, kept current automatically
• Facility network management
• Public find-care search
• Four sign-in page layouts, and your own addresses show only your own links
• Guided onboarding: a checklist, a secure file drop, and a template for every list we load

Backoffice for TPAs and groups

• A group running several plan accounts gets its own branded Backoffice console
• Claimaro links the group's accounts to it at setup
• A dashboard of the group's accounts
• The group's people, with roles, invites, and password resets
• The group's Admins edit their own logo, colors, and profile
• Open any account in a new tab from Backoffice
• The group's own web address, with its own branded sign-in
• Help Center pages inside Backoffice