Claims Adjudication & Prior Auth — payer-grade workflow on a platform that auditors trust.
Workflow automation for the payer-side processes that define healthcare insurance and TPA operations — claims adjudication, prior authorisation, eligibility verification, and provider network management. Audit-ready by design, integrated with provider and member systems, and structured for the SLA standards regulators and members both expect.
Defensible records of every adjudication and authorisation
Claims and prior-auth processes modelled as executable BPMN
Authorisation decisions surfaced live, not in batch
Integrated with provider and member-facing systems
01 / THE CHALLENGE
Claims and prior-auth running on email, faxes, and end-of-day batches — under SLA standards that no longer accept that.
Healthcare payers and TPAs handle thousands of claims and prior-authorisation decisions every day — eligibility checks, medical necessity reviews, provider validation, claims adjudication. Many of them still happen on email, fax, and end-of-day batch reconciliation that strains both regulator SLAs and member experience.
The cost shows up as regulator findings, member complaints, provider abrasion, and the operational margin lost when scarce medical reviewers spend time on cases that should have been auto-adjudicated. Recent regulatory cycles increasingly demand defensible audit trails, faster decisioning SLAs, and the ability to evidence both consistency and clinical judgement when decisions are challenged. The traditional response — adding more reviewer headcount, more email queues, more standalone GRC tools — addresses fragments but not the underlying structure. Claims Adjudication & Prior Auth Automation puts the regulated process itself on a governed platform: every step modelled, every decision traceable to its evidence base, every exception captured with the rationale that auditors will ask about.
02 / THE APPROACH
Four phases. Each one ships agent capability into citizen channels.
CODE81 delivers the Citizen Service Agent in four phases — designed so the agent is in production handling real citizen traffic by the end of the second phase, not at the end of a 12-month transformation programme.
- Process audit & regulator mapping — Audit existing claims and prior-auth workflows. Map them to the regulatory frameworks that apply — local healthcare regulators, network agreements, payer accreditation standards. Prioritise the workflows with highest volume, SLA exposure, or audit risk.
- Platform build & first workflow — Build the workflow platform with audit logging, role-based access, and integration with claims, eligibility, and provider systems. Deploy the first BPMN-modelled workflow into production — typically prior authorisation or auto-adjudication.
- Additional workflows & provider integration — Roll out additional workflows on the same governed foundation — adjudication exceptions, appeals, provider validation, network management. Extend integrations with provider portals so prior-auth requests and claims status flow without manual intervention.
- Audit, monitoring & handover — Lock in compliance analytics, exception monitoring, and the operational handover to the payer's claims and medical management teams. The platform becomes the institution's regulated payer operating layer.
03 / THE SOLUTION
Six components that make up a production-grade Claims Adjudication & Prior Auth Automation.
The full reference architecture — what gets built, how the pieces fit together, and where the governance controls sit.
/ COMPONENT 01
BPMN Adjudication Engine
The platform itself — claims and prior-auth processes modelled as executable BPMN that medical management teams can read, govern, and refine without code rewrites.
/ COMPONENT 02
Auto-Adjudication Rules
Configurable adjudication rules that route straightforward claims to automated decisioning — leaving medical reviewers focused on cases that need clinical judgement.
/ COMPONENT 03
Prior Authorisation Workflow
Real-time prior-auth decisioning with medical necessity rules, evidence capture, and structured handoff to clinical reviewers when needed.
/ COMPONENT 04
Audit Trail & Evidence
Every adjudication and authorisation logged with timestamp, reviewer, evidence, and rationale — defensible records that regulators and providers can both inspect.
/ COMPONENT 05
Provider & Member Integration
Real-time integration with provider portals, eligibility systems, and member-facing channels — claims and authorisations flow without manual handoff.
/ COMPONENT 06
Exception & Appeals Workflow
Structured workflows for exceptions and appeals — every override traceable to who approved it, on what basis, and against which evidence.
Connect
Platform integrated with claims, eligibility, provider, and member-facing systems.
Automate
BPMN-modelled adjudication and prior-auth workflows execute claim and authorisation processing.
Decide
Medical reviewers and adjudicators receive structured cases with evidence and clinical context.
Audit
Every decision, exception, and appeal logged with full traceability for regulators and providers.
What citizen service leaders fund this for.
Industry benchmarks across the categories CODE81 delivers for public-sector clients. Sourced from analyst firms and sector research — not internal estimates.
Reduction in adjudication cycle time when manual workflows move to BPMN auto-adjudication platforms
Auto-adjudication rate achievable on straightforward claims when rules are codified into platform workflow
Prior-auth decisions surfaced live versus batch reporting cycles
05 / TECHNOLOGY
Built on enterprise AI platforms with public-sector data residency.
Reference architecture — the platforms and integration patterns CODE81 uses to deliver the Citizen Service Agent. Specific platform choices tuned to each client's existing estate and regulatory context.
Workflow & Adjudication
Payer & Provider Integration
Governance
/ Engagement Disclosure
This is a forward-looking use case CODE81 designs and delivers for government and public-sector clients across the region. Live engagement details, reference architectures, and customer references are available under NDA on request.
06 / RELATED USE CASES
More government use cases.
Have claims and prior-auth running on
email and fax queues?
We've built payer-grade workflow platforms for healthcare insurers and TPAs across the region — designed to the audit standards regulators apply when SLAs slip. Send us the use case and we'll respond with the architecture, governance shape, and a 30-minute scoping call — usually within the same business day.
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