A priority-rules engine that prices every medical claim against your plan design, updates accumulators in real time, and pays providers — built for self-funded plans, healthshares, and TPAs. Published pricing, and zero per-claim fees.
Every claim runs the same defined path — eligibility, benefits, pricing, cost-sharing — with a full audit trail behind it.
Rules evaluate in a defined order against each claim, so adjudication is deterministic and explainable — not a black box you have to reverse-engineer.
Prices against your fee schedule with a usual-and-customary fallback, then applies deductible, coinsurance, and copay exactly as your plan defines them.
Deductible, out-of-pocket, and healthshare annual limits update as each claim adjudicates — so the next claim prices against current balances, not last night's batch.
837 claim intake, 835 remittance generation, and eligibility transactions with clearinghouse connectivity — built in, not a separate module or middleware contract.
Flags duplicates and near-duplicates — including the same service arriving once from the provider by EDI and again from the member portal with slight variations.
Always-on audit logging and role-based adjudicator permissions, with PHI encrypted in transit and at rest and each client on its own isolated database.
Claims that satisfy your rules process straight through without a keystroke. Anything that needs judgment — a missing authorization, an eligibility mismatch, a suspected duplicate — pends into the adjudicator queue with the reason attached, so your team works exceptions instead of re-keying the routine.
We don't publish a benchmark auto-adjudication percentage, because the honest answer depends on your plan design and claim mix, not our marketing. Bring your actual plan to a walkthrough and watch the engine run against it.
Much of this market bills $0.50 to $2 for every claim processed, so the better your adjudication team performs, the larger your invoice. Claimaro is base plus PMPM only. Your claim volume can double and your platform cost doesn't move a dollar — the cost of adjudicating is not indexed to how much adjudicating you do.
Claims adjudication software is the engine that decides what a health plan pays on a medical claim. It takes the claim in, confirms the member is eligible, matches it to the right benefit plan, prices it, applies cost-sharing (deductible, coinsurance, copay), updates the member’s accumulators, and produces the payment and the explanation of benefits. For a self-funded plan, healthshare, or TPA, it is the core of the operation.
Rules are evaluated in a defined priority order against each claim: eligibility, benefit matching, pricing against your fee schedule (with a usual-and-customary fallback), then cost-sharing. Accumulators — deductible, out-of-pocket, and healthshare annual limits — update in real time as each claim adjudicates, so the next claim prices against current balances rather than a nightly batch.
Yes — claims that satisfy your rules process straight through, and anything that needs a human is pended into the adjudicator queue with the reason attached. We do not publish a benchmark auto-adjudication percentage, because the honest answer depends entirely on your plan design and claim mix. The better test is to bring your actual plan to a walkthrough and watch the engine run against it.
Yes, natively — 837 claim intake, 835 remittance generation, and eligibility transactions, with clearinghouse connectivity built into the platform rather than sold as a separate module or a middleware contract.
Yes. Claimaro flags duplicates and near-duplicates — including the common case where the same service arrives once from the provider via EDI and again from the member through the portal, with slight variations. Catching that before payment is one of the most direct ways adjudication software pays for itself.
Claimaro is published, flat pricing: from $3,500/month + $5 PMPM with a $15,000 setup, and zero per-claim fees. Much of this market bills per claim processed, which means the cost of adjudication rises with your volume. Ours does not.
Twenty minutes, your plan design, live in the product. Or read the seven systems it takes to run a TPA, see how the engine fits into a full self-funded plan platform, or see how Claimaro compares to the incumbent claims platforms.