Real-Time Claims
Adjudication.
Your AI Adjudicator for Instant Zero-Touch Approvals. AI processes incoming claims in real-time against digitized policy rules, benefit limits, fee schedules, and member eligibility. Clean claims are auto-adjudicated and approved instantly with no human touch.
Straight-through processing before the patient leaves.
From claim submission to settlement in milliseconds. Human reviewers focus only on flagged cases.
Dynamic Rules Engine
Applies your policy limits, sub-limits, and exclusions in real-time. Clean claims auto-approved in milliseconds with zero human intervention.
Eligibility and Pre-Authorization
Automates eligibility checks and Letters of Guarantee for complex procedures directly within the clinical workflow. Instant clarity for providers and insurers.
Live Co-Pay Calculations
Calculates precise deductibles and co-pays at the front desk. Guarantees exact upfront collection and eliminates post-visit accounting reconciliation.
Intelligent Split-Billing
Separates member out-of-pocket costs from insurer-covered items instantly. Prevents billing disputes and eliminates manual audits.
AI Decision Support
Complex or flagged claims are routed to human reviewers with AI-generated summaries including rule matches, risk scores, and recommended actions.
Batch Reconciliation
Syncs processed claims daily via automated batch reporting. Simplifies finance accounting and ensures all digital payouts match bank deposits.
Submit, validate, decide, settle. In under a second.
50 to 70% cost reduction. 80%+ straight-through rate. Sub-second decisions.
50-70%
Claims processing cost reductionReduces claims processing cost and turnaround from days or weeks to seconds. Drastically cuts manual headcount and eliminates repetitive review of clean claims.
80%+
Straight-through processing rateClean claims auto-approved with zero human touch. Your claims team focuses exclusively on complex, flagged cases where human judgment adds real value.
<1s
Average adjudication timeNear-instant claim decisions at the point of care. Providers and patients get immediate clarity. No more waiting weeks for reimbursement or approval.
Global Ready
Asia-first, world-readyInsurers across Asia still rely heavily on manual claims review teams processing paper and PDF submissions. AI adjudication compresses the entire cycle and scales without headcount.
Connect to your core system or run natively.
Standalone via Open API
Submit claims via REST API and receive adjudication decisions in real-time. Integrates with any core system, TPA platform, or claims management tool.
Native on Mazecare Insurance OS
Claims flow from provider OS with structured clinical data, adjudicate in real-time, and settle automatically. End-to-end from consultation to payment.
AI Model Agnostic. Your AI, Your Choice.
Choose or bring your own models for decision support, risk scoring, and claims intelligence.
Pre-integrated Models
Decision support and risk scoring models optimized for health insurance claims, ready out of the box.
Open-source Models
Run open-source models within your own infrastructure for full data sovereignty and compliance.
Custom Fine-tuned
Train on your claims history and policy-specific patterns for higher accuracy on your book of business.
Bring Your Own API
Connect any external AI, risk engine, or analytics API. Use existing enterprise agreements.
The only real-time adjudication built into the clinical workflow.
| Feature | Legacy TPAs | Core / In-House | AI Claims Scanners |  |
|---|---|---|---|---|
| Real-time adjudication at point of care | Limited | |||
| Zero-touch auto-approval for clean claims | Partial | Partial | ||
| Structured clinical data input | ||||
| Live eligibility checks | Limited | Partial | ||
| Digital pre-authorization and LOG | Partial | Limited | ||
| Live co-pay and deductible calculation | ||||
| Intelligent split-billing | ||||
| AI decision support for flagged claims | Partial | |||
| FWA blocking before payment | Reactive | Reactive | Partial | |
| Automated batch reconciliation | Partial | Partial | ||
| Provider workflow integration | ||||
| Processing time under 1 second | Partial | |||
| Own AI-native OS | Mazecare OS |
Frequently asked questions.
Clean claims that pass all policy rules, eligibility checks, and validation are auto-approved instantly with no human review. Mazecare achieves 80%+ STP rates, meaning only flagged or complex claims require human attention.
Sub-second. The adjudication engine applies rules, checks eligibility, calculates co-pays, and returns a decision in milliseconds. Claims are settled before the patient leaves the clinic.
Flagged claims are routed to human reviewers with AI-generated decision summaries including matched rules, risk scores, supporting evidence, and recommended actions. Reviewers make faster, better-informed decisions.
It can. Mazecare handles eligibility, adjudication, split-billing, and reconciliation end-to-end. Many insurers use it to bring claims processing in-house, eliminating TPA fees and gaining full data transparency.
Via REST APIs and HL7 FHIR. Connect to your core administration system, member databases, and finance platforms. Or run natively on Mazecare Insurance OS for end-to-end coverage.
Digital pre-auth and Letters of Guarantee are built in. Complex procedures trigger automated approval workflows directly within the provider clinical system, providing instant clarity and lowering financial risk.
Ready to adjudicate claims in real-time?
See the adjudication engine process live claims against your actual policy rules.