Claims adjudication built to protect your loss ratio.
Rules-first automation reads every claim against your benefit rules, clears the clean ones straight through, and routes only the exceptions to human reviewers. Decisions happen at the point of the claim, not in a report after the money has left.
Straight-through where it's earned, human review where it's needed.
Rules-first automation
Benefit limits, exclusions, tariffs, and eligibility are evaluated automatically on every claim, in a consistent order, every time — no reliance on the memory of an individual assessor.
Straight-through processing
Clean claims that satisfy every rule are cleared without a human touch, so your reviewers spend their time only on the claims that actually need judgement.
Exception routing with a human in the loop
Adjudication runs behind a hard accuracy gate. The platform will not deny a claim automatically beyond a strict false-denial threshold — exceptions go to people, with the full context attached.
Nigerian by construction
NHIA-aware tariff structures, an NDPA 2023 aligned data posture, and monetary values processed as integer kobo end to end — no floating-point money, no rounding drift.
From intake to decision.
Intake and normalise
Claims arrive and are normalised against your member and benefit model, so every downstream check reads the same clean, structured record.
Evaluate and screen
Benefit rules run first, alongside a fraud, waste and abuse screen. Each state change is written to an append-only event log before it takes effect.
Route the outcome
Clean claims clear straight through. Exceptions and flagged patterns route to human reviewers and investigations, with the decision trail intact.
The loss ratio is decided one claim at a time.
The loss ratio — the share of premium paid back out in claims — is not moved by a quarterly report. It is moved by thousands of individual decisions, each made while the claim is still in front of you. Manual vetting puts clean claims in the same queue as the ones that need scrutiny, and cost follows delay.
Automated adjudication changes the economics of that queue. Valid spend clears quickly, so providers are paid and members are served. Questionable spend is held back and examined before money leaves. Your reviewers stop spending their day rubber-stamping the obvious and start spending it on the claims where their judgement is worth the most.
Decide at the point of the claim, not in a report after the money has left.
Claims adjudication, answered.
What is automated claims adjudication?
Does the platform ever deny a claim automatically?
Is Ajé built for the Nigerian HMO market?
How does adjudication protect the loss ratio?
See adjudication against your own book.
We run a working session with your operations team, walking through adjudication on the workflows you handle every day.