Claims processing that adjudicates, documents, and pays.
TL;DR. TechSure processes insurance, healthcare, and warranty claims. Inputs are the claim file plus supporting documents. Outputs are adjudicated decisions with documented rationale, in your system of record. Across our pilot clients in the last 12 months, the appeal-overturn rate is 0.4 percent on adjudicated decisions.
What kinds of claims does TechSure process?
We process insurance claims, healthcare claims, and warranty claims. Inputs are the claim file plus supporting documents. Outputs are adjudicated decisions with documented rationale, in your system of record. We work with payers, providers, TPAs, and self-insured employers.
What we process, in plain terms
- Medical and dental claims (CMS-1500, UB-04, ADA)
- Property and casualty claims (auto, home, commercial)
- Workers' compensation claims (FROI, SROI in US; First Report in UK)
- Liability and product warranty claims
- Travel and accident claims with multi-jurisdiction routing
A live demo of this discipline's workflow mounts here. Static metrics shown until then.
How does a claim move from intake to decision?
Five stages, instrumented end to end. Each claim carries an audit trail, the source documents, and the adjudication rationale. The decision is final, with documented reasons, before the claim is paid or denied.
The five-stage workflow
- Intake. The claim arrives through your channel of choice: EDI 837, clearinghouse, web form, email, or API. The file is hashed, timestamped, and indexed.
- Verify. Eligibility, prior authorization, and policy status are checked against the system of record. Mismatches are flagged, not auto-resolved.
- Adjudicate. A claims specialist applies your policy rules: covered, not covered, partial, appeal. The decision is documented with code references.
- Approve. A senior reviewer signs off the decision. The claim is queued for payment or routed to the appeal workflow.
- Pay. The approved amount is queued for payment through your disbursement system. The claim is closed with the full audit trail.
How is the engagement structured, and what does it cost?
Statement-of-work, with a fixed monthly retainer sized to claim volume, claim type mix, and turnaround SLA. We do not bill per claim. The retainer covers the adjudicators, the senior reviewer, the engineers, the dashboard, and the named account owner.
What the monthly price covers
- Named claims adjudicators trained on your policy and coding rules
- Senior claims reviewer for the decision and the appeal
- A TechSure engineer on the pod, owning the platform integrations and EDI mappings
- Engagement dashboard with live accuracy, cycle time, and appeal rate
- Monthly review with the named account owner and a TechSure partner
FAQ
Common questions on Claims Processing
What kinds of claims does TechSure process?
We process insurance claims, healthcare claims, and warranty claims. Inputs are the claim file plus supporting documents. Outputs are adjudicated decisions with documented rationale, in your system of record.
How accurate is the adjudication?
Across our pilot clients in the last 12 months, the appeal-overturn rate is 0.4 percent on adjudicated decisions. We work inside your policy, your coding rules, and your compliance framework.
Can you handle appeals?
Yes. We process first-level appeals inside your policy. Second-level or external appeals are routed to a senior reviewer with the full claim history attached. We do not sign denials without a documented rationale.
What about US HIPAA and UK GDPR compliance?
We sign BAAs for HIPAA scopes. We sign DPAs for UK GDPR and EU GDPR. Sensitive queues are routed to a named subset of agents with background-check clearance and audit logging.
Do you sign off on denials?
We prepare the decision and the rationale, and we hand it to your claims manager for sign-off. We do not sign denials on behalf of your company.
Have a workflow that needs a team behind it?
Send a brief. We come back in 24 hours with a scope, a price band, and a named engineer.
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