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National adjudication volume supported
Employer-specific benefit logic governed
Manual interpretation burden targeted
A national TPA was responsible for applying plan-specific benefits across 240 employer plan designs while processing 19M claims per year. The environment required precise interpretation of Summary Plan Descriptions, benefit schedules, network terms, deductibles, out-of-pocket logic, carve-outs, and coordination-of-benefits rules.
The bottleneck was manual plan interpretation. Claims teams could not rely on one standard adjudication rulebook because each employer plan required its own machine-readable benefit logic, and legacy systems did not consistently encode those differences.
The financial and operating impact was clear. Manual interpretation consumed 2,400 FTE-hours per month, routine claims waited behind exception queues, and inconsistent encoding increased the risk of incorrect payments, rework, and employer-client dissatisfaction.
The executive trigger was the need for a governed adjudication layer that could apply plan-specific rules at claim resolution time. Leadership needed Claims Hyper-Adjudication to turn employer plan documents into structured benefit logic, standardize decisioning, and preserve human review for complex exceptions.
Novacis Digital deployed Claims Hyper-Adjudication, an AI-powered adjudication layer built to apply employer-specific benefit rules at claim resolution time.
The solution ingested each employer’s Summary Plan Description and benefit schedule, extracted applicable adjudication rules, structured plan-specific benefit logic, standardized claims data, and evaluated claims against the correct ruleset for each plan design.
Exceptions were routed to reviewers with plan context, anomaly signals, and decision support.
The technical differentiation was governed plan-design encoding at multi-plan TPA scale. Claims Hyper-Adjudication combined document intelligence, rule interpretation, claims standardization, anomaly detection, and exception escalation in one decisioning workflow.
Claims teams retained control over edge cases, reviewer decisions, and final claim outcomes.
This shifted the operating model from manual plan interpretation to AI-prepared benefit-rule adjudication with human-controlled exception review.
Claims Hyper-Adjudication Capabilities
TPA Decisioning Features
Novacis Digital implemented Claims Hyper-Adjudication in two stages: a 6-week adjudication pilot for complex employer plan designs, followed by a 10–12 week enterprise expansion across the TPA’s 240-plan operating model. The initial rollout focused on plans where deductible logic, network rules, coordination-of-benefits terms, carve-outs, and stop-loss thresholds created the most manual effort.
Early wins included machine-executable benefit logic, standardized claim inputs, plan-specific rule application, anomaly detection, and exception routing with reviewer context. This gave claims and operations leadership proof that the TPA could reduce manual interpretation while preserving human control over complex exceptions and final claim outcomes.
Addressed 2,400 FTE-hours per month of manual interpretation cost pressure by operationalizing employer benefit rules for adjudication use.
Applied plan-specific rules across the 240-plan operating model, giving claims teams a faster path from plan language to claim action.
Improved fiduciary control by standardizing benefit-rule execution, reducing payout variability tied to inconsistent manual interpretation.
Supported Claims Hyper-Adjudication across 19M annual claims, proving the model could scale with national TPA volume.
Shifted operations from repeated plan-document lookup to targeted exception review, helping claims teams reserve manual attention for claims requiring judgment.
