Claim adjudication, automated and audited.
The agent reads the claim file, the medical records, the policy wording, and the hospital tariff list. It produces a cited recommendation: approve, partial-approve, deny, or escalate. Reviewers see the recommendation in their existing console; nothing about their workflow changes — and a meaningful share of the volume arrives already decisioned with the rest cited and routed. The touchless share is tuned per pilot; pre-revenue today.
What the engagement ships
Indexed policy + tariff corpus
Your policy wordings, clinical guidelines, hospital tariff lists, IRDAI bulletins — ingested into the Context Mesh and ready for citation.
Intake adapter
Connects to your existing claim-intake (portal, TPA platform, file drop). No new front-door for your customers or hospital partners.
Outbound adapter
Writes decisions back into your case-management system. Cashless approvals push to the hospital-network portal.
Golden eval set
≥50 representative claims per product line, signed off by your medical director. CI-blocking eval gate.
Claim adjudication FAQ
What touchless rate should we expect?
Touchless rate is tuned during each pilot's shadow run, against the customer's own historical claims. Vihaya is pre-revenue and has not yet completed a paid pilot, so we don't publish a measured range — the first design-partner engagements will set the reference. Industry peers running similar architectures report a wide spread by product type.
Does it work for both cashless and reimbursement?
Yes. Cashless requires sub-second decision latency and ties into the hospital-network portal. Reimbursement is asynchronous and tolerates longer processing for richer documentation review. Same engine, two operating modes.
How is the decision audit-defensible?
Every decision row stores citations — chunk IDs pointing to the exact policy clause, clinical guideline, and tariff entry the agent grounded on. Reviewers and IRDAI auditors can reconstruct the rationale years later from cold storage.
What about the regional-language documentation?
Indian claim documentation is bilingual at best and trilingual often. Foundation models handle it natively; the Context Mesh indexes original-language plus English normalisation so retrieval works across the language barrier.
Want to see this in your environment?
30-minute discovery call. Draft SOW within 5 business days.
Talk to us about a pilot →