Claims Adjudication · Deterministic · Governed · Auditable

Every Claims Decision, Traceable to the Rule That Made It.

Manual adjudication is slow and opaque, and denials that claimants can’t understand become appeals and complaints. Compile coverage and adjudication rules into governed decision packages — every outcome carries reason codes, clause citations, and a signed trace.

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Zero AI at runtime. Deterministic. Auditable. Traceable.

The problem

Adjudication is slow and inconsistent

Manual review creates backlogs, and the same claim gets different outcomes depending on the adjuster. Adjudication rules should be deterministic and auditable — not dependent on who handles the file.

Denials are opaque

When a claim is denied, the claimant can’t see why. Every denial should carry traceable reason codes tied to a specific policy or coverage clause, not a black-box outcome.

Audits mean reconstruction

Reconstructing an adjudication for a regulator or an appeal takes weeks of log archaeology. Every decision should carry a signed trace — not require forensic reconstruction after the fact.

How Sertainly Helps

Coverage & limit checks

Policy status, coverage terms, and limits compiled into deterministic decision packages, evaluated the same way on every claim.

  • Policy and plan status validation before adjudication
  • Deductible, sublimit, and aggregate-limit checks
  • Exclusion and endorsement handling
  • Routing by date of loss or date of service

Traceable outcomes

Every outcome — approval, partial, or denial — carries reason codes citing the specific clause that produced it.

  • Denial reason codes tied to specific policy clauses
  • Evidence-backed trace package for appeals
  • Consistent outcomes across adjusters and systems
  • Structured evidence request when documentation is missing

Defensible on review

Every adjudication replays against the rules in force on the claim’s date, so a decision made last year is reproducible today.

  • Signed decision trace for disputes and regulators
  • Reproduce any adjudication against the rules in force on its date
  • Version-pinned coverage logic with governed builds
  • Immutable audit trail for regulatory review

Claims adjudication: professional service claim

A claim is submitted for evaluation. Sertainly checks coverage, authorization, and cost-share terms, returning a deterministic outcome with full trace.

evaluate_case input

{
  "version": 3,
  "case": {
    "claim": {
      "service_code": "99214",
      "billed_amount": 220,
      "date_of_service": "2026-05-14"
    },
    "member": {
      "plan_status": "ACTIVE",
      "deductible_met": true
    },
    "authorization": "AUTH_OK"
  }
}

evaluate_case output

{
  "status": "ok",
  "outputs": {
    "tags": ["APPROVED"],
    "reason_codes": [
      "COVERAGE_ACTIVE",
      "AUTH_ON_FILE",
      "DEDUCTIBLE_SATISFIED"
    ],
    "facts": {
      "allowed_amount": 176,
      "member_responsibility": 35
    }
  },
  "trace_id": "tr_claim_8f4d…"
}

the trace · GET /api/public/v1/traces/{id}

{
  "trace_id": "tr_claim_8f4d…",
  "applied_rules": [
    { "id": "verify_coverage", "phase": "validate",
      "emitted": { "reason_code": "COVERAGE_ACTIVE" } },
    { "id": "check_authorization", "phase": "validate",
      "emitted": { "reason_code": "AUTH_ON_FILE" } },
    { "id": "adjudicate_cost_share", "phase": "evaluate",
      "emitted": { "tag": "APPROVED", "reason_code": "DEDUCTIBLE_SATISFIED" } }
  ],
  "skipped_rules": [
    { "id": "route_to_review", "reason": "when=false" }
  ]
}

Applies across

The same decision layer, wherever this problem shows up.

Insurance →Healthcare →

Sertainly doesn't replace your existing platforms — it supplies the governed, traceable decision packages they call.

Ready to make every claims decision defensible?

Compile policy into governed decision packages. Execute deterministically with full trace, provenance, and audit controls. Same decision layer across every industry.

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