Member Identity Platform

AI adjudicator

How much the model may do, and the model it runs on.

OffModel never called. Rules and examiners only.ShadowModel reviews and is graded; examiners see nothing.AssistRecommendations pre-fill the examiner's panel; a person records every outcome.AutoValidated, high-confidence approvals and denials are applied without a person.

Model (Amazon Bedrock model or inference profile ID)Amazon Nova models need no Marketplace subscription. Anthropic models work through the same API once the account's subscription is active.RegionConfidence floorBelow this the recommendation is advisory onlyBatch sizeConcurrencyMax output tokensTemperature

Cache the system prompt Send member name, date of birth and ID to the model

Outcomes the model may apply in auto mode

approvedenypendinvestigate

Rules engine

Deterministic edits that run on every claim before any model is involved.

Timely filing limit (days)Auto-adjudication ceiling (USD)Above this an examiner must sign offDuplicate window (days)

Procedures requiring prior authorisation (CPT/HCPCS)

Authorisation number patternAdvanced imaging codesRoutine diagnosis prefixesImaging with these diagnoses needs clinical supportPhysical therapy codes (visit limit)

HMO and EPO plans cover out-of-network care Out-of-network emergency care is payable at the in-network level

Pricing

In-network factor, professionalAllowed amount as a share of billedIn-network factor, institutionalOut-of-network factor

Specialist specialties (specialist copay applies)

Assistant

ModelMax lookups per question

Claims policy

AI adjudicator

Rules engine

Pricing

Assistant