Integration and normalization of claims data, contract formularies, and pricing benchmarks across disparate healthcare data sources for actuarial analysis.
AI-powered field mapping across 837, 835, flat files, and custom PBM formats. No manual configuration—system learns structure from headers and validates against healthcare standards.
Every ingested record validated against NDC directories, ICD-10 codes, provider NPIs, and contract formularies. Errors flagged with specific remediation steps before processing continues.
Fuzzy matching algorithms identify duplicate claims across PBM, TPA, and carrier systems. Resolves conflicts using hierarchical trust scoring—actual adjudicated claim data wins.
All data normalized into actuarial-grade common format. Compatible with industry simulation tools, fiduciary reporting standards, and regulatory submission requirements.
Reject incomplete records upstream before they corrupt analysis. Required fields enforced per claim type—Rx claims need NDC, medical claims need procedure codes, all need member IDs.
Enrich claims with AWP, WAC, NADAC, and MAC pricing from First Databank and Medi-Span. Historical pricing tracked—catch retroactive spread adjustments and AWP inflation schemes.
Map every claim to its governing contract provision. Automated lookup tables link NDCs to formulary tiers, providers to network rates, and specialty drugs to carve-out terms.
Comprehensive governance framework for board members and plan fiduciaries — defense-ready documentation and continuous oversight infrastructure.
Timestamped audit trail with complete chain of custody
EBITDA quantification and board-ready financial models
Cross-system verification and data integrity validation
Automated clause extraction and guarantee enforcement
Monte Carlo simulations and credibility-weighted forecasts
Transaction-level anomaly detection and forensic alerts
ERISA compliance monitoring and DOL audit readiness
AI-powered trend forecasting and intervention modeling