Dual-Sided AI Claims Intelligence

Smarter claims.
Faster decisions.
Both sides.

ARIA is the only AI claims processing platform built for both payers and providers — delivering real-time adjudication, denial intelligence, and appeal ROI on a single auditable platform.

Explore Solutions → See How It Works
HIPAA Compliant
SOC 2 Type I In Progress
SHA-256 Audit Trail
🤖
~96%†
Claims Auto-Processed
Blue · Green · Orange tiers
🔍
16
Payer Tool Signatures
ClaimsXten, PXDX, Optum EDC + 13 more
🔗
1.35M+
NCCI Edit Pairs Enforced
Live at adjudication
📜
7-Year
Audit Trail Retention
SHA-256 hashed · Litigation-ready
~96%†
Automation Rate
Blue + Green + Orange tiers
86
Microservices
Event-driven · Independent
16
Payer Tool Signatures
ClaimsXten · PXDX · +13
1.35M+
NCCI Edit Pairs
Live at adjudication
1,073
LCD Policies Loaded
+ National Coverage Determinations
7-Year
Audit Retention
SHA-256 · Litigation-ready
Solutions

Built for both sides of the claims transaction.

Payers get AI-powered adjudication with full audit compliance. Providers get denial intelligence with ROI-ranked appeal guidance. One platform. One connected learning loop built on every decision made across both sides of the transaction.

Built for health plans, TPAs, and payer-side adjudication teams. ARIA's Payer Portal brings AI Multi-Agent Debate reasoning, NCCI/MUE enforcement across 1.35M+ edit pairs, LCD/NCD coverage validation, E&M MDM documentation scoring, and graduated confidence-tier automation — all in one fully auditable workflow with SHA-256 hashed decisions retained for seven years.

⚡
Pre-Submission Claim Scoring1
Score claims before adjudication using configurable confidence thresholds. AI Multi-Agent Debate ensures no single-model decision on complex or high-value claims.
In Build
🔗
NCCI / MUE Enforcement
1.35M+ NCCI edit pairs enforced at adjudication. Unbundling detection, mutually exclusive procedure identification, modifier validation — all rule-driven, zero hardcoded logic.
Live
📋
LCD / NCD Coverage Enforcement
1,073 LCD policies enforced at line-item level before adjudication2. Local and National Coverage Determinations checked in real time on every claim.
Live
🧠
E&M Medical Decision Making
AI-driven MDM analysis validates E&M code levels against clinical documentation. Flags documentation insufficiency before payment releases — no post-pay take-backs.
Live
🎲
Random Audit Sampling3
Configurable audit rates by confidence tier: Blue 3%, Green 7%, Orange 100%. Fully rule-driven — no hardcoded rates. Complete chain-of-custody in the audit trail.
Live
⚖️
Litigation Export
Court-ready PDF package generation from the complete AI decision audit trail — every agent vote, every confidence score, every SHA-256 hash. 7-year retention, litigation-ready on demand.
Live
Payer Adjudication Workflow
INTAKE VALIDATION AI ADJUDICATION CONFIDENCE TIER OUTCOME 📋 Claim Submitted EDI · FHIR · ERA · API 🔗 NCCI / MUE 1.35M+ edit pair checks 📋 LCD / NCD Coverage enforcement 🧠 E&M MDM Documentation scoring 🤖 AI Multi-Agent Debate A1 A2 A3 SHA-256 hashed consensus 🔵 90–100% — BLUE 🟢 80–89% — GREEN 🟠 75–79% — ORANGE 🟡 70–74% — YELLOW 🔴 <70% — RED ✅ Auto-Approved Blue + Green Audit sampled ⚠️ Flagged + Audited Orange — 100% audit review 👤 Human Review Yellow / Red tiers Adjuster queue 🔐 Every decision cryptographically hashed (SHA-256) · 7-year audit trail · Litigation export available at any stage

Built for mid-size RCM companies, billing teams, and provider groups. ARIA identifies which payer editing engine denied the claim, scores the ROI of fighting it, surfaces the exact fix, and ranks your entire denial queue by expected recovery — so your staff stops guessing and starts recovering.

🔍
Payer Tool Attribution
ARIA identifies which payer editing engine generated each denial — ClaimsXten, Cigna PXDX, Optum EDC, and 13 others. 98% confidence signatures. No competitor offers this capability.
Live
💰
Appeal ROI Engine4
Every denial receives a recommendation: FIGHT, EVALUATE, WRITE-OFF, or ESCALATE — based on MGMA 2024 win rates, $75 appeal admin cost, and 2× ROI threshold. Bayesian learning from real outcomes.
Live
📡
Systematic Denial Detection
Three identical CARC+CPT+payer occurrences triggers a systematic flag. PXDX clusters auto-escalate to legal track with DOJ investigation cross-reference. Clinical appeals on administrative denials waste money.
Live
📥
Multi-Format Denial Ingestion
ERA/835, payer API, EOB upload, CSV, and manual entry. All five paths normalize to the identical AI pipeline — format doesn't change intelligence quality.
Live
🛡️
Pre-Submission Validation
5-layer pre-validation catches NPI errors, gender/CPT mismatches, missing modifiers, and NCCI bundling before submission. Every denial caught pre-submission = 30–60 days of cash flow saved per claim.
Live
🎯
Fraud Early Detection
Statistical outlier detection on billing patterns flags anomalies before your payer's RAC auditor does. Protects your clients from False Claims Act exposure and recoupment audits.
Live
Provider Denial Recovery Workflow
DENIAL INTAKE ATTRIBUTION AI ANALYSIS ROI TRIAGE ACTION ❌ Denial Received ERA · EOB · API · CSV 🔍 Tool Attribution 16 payer engine signatures ClaimsXten Cigna PXDX Optum EDC + 13 others ⚡ Systematic Flag ≥ 3 DOJ cross-ref applied 🧠 AI Analysis CARC / RARC Classification Clinical vs. Administrative Win Rate (Bayesian Model) Appeal Fix + Modifier Rec. Confidence scored + evidence chain ⚔️ FIGHT ROI >2× · High win rate 📋 EVALUATE Borderline · Manager review ⚖️ ESCALATE Systematic / DOJ → Legal ✖ WRITE-OFF ROI <1× · Admin cost exceeds 📝 Appeal Letter AI-generated · Fix specified · Filed Recovery tracked 🔎 Manager Review Escalation or override decision ⚖️ Legal Track Attorney referral · DOJ package 📊 Logged + Learned Outcome updates win model ↺ Every resolved denial updates the Bayesian win model — accuracy improves continuously 🔐 Complete audit trail on every recommendation · SHA-256 hashed decision chain · Fully traceable
How It Works

From intake to decision in one unified pipeline.

Every claim passes through a multi-stage AI pipeline. Each stage is independently traceable, auditable, and configurable. No black boxes. No single-model decisions. Every output hashed and recorded in the 7-year audit trail.
📥
Ingest
EDI · FHIR · ERA
Payer API · CSV
✅
Validate
NCCI · MUE
LCD/NCD · E&M
🤖
AI Debate
Multi-Agent
Consensus
🎚️
Route
Blue · Green
Orange · Yellow · Red
⚙️
Adjudicate
Auto-approve or
Human review
📚
Learn
Outcome → Bayesian
model update
Graduated Automation

Intelligent thresholds. Not binary rules.

Five confidence tiers balance automation efficiency with appropriate human oversight. Every threshold is fully configurable — not hardcoded. Start conservative with Blue-only automation, then expand tier-by-tier as AI accuracy is validated against your actual claim mix and payer composition.
🔵
90–100%
Auto-Approve
High confidence. Minimal risk. Straight-through processing. Random audit sample: 3%.
🟢
80–89%
Auto-Approve
Good confidence. Acceptable risk profile. Random audit sample: 7%3.
🟠
75–79%
Auto + Audit
Moderate confidence. Auto-approved but flagged for 100% audit review.
🟡
70–74%
Human Review
Lower confidence. Routes to adjuster queue. Every decision trains the model.
🔴
<70%
Mandatory Review
High risk. Mandatory human adjudication. No automatic processing.
~96%†
Blue + Green + Orange tiers automatically process the majority of routine claims — leaving your adjusters focused on cases that genuinely require human judgment.
See It in Action →
Platform Architecture

86 microservices. One event-driven core.

Asynchronous event messaging between all 86 services — no direct service-to-service calls, no shared data stores, no synchronous coupling. Every service is independently deployable. Every decision is traceable end-to-end. ARIA scales horizontally without architectural rework.
Claim Intake
EDI / X12
FHIR R4
ERA / Remittance
Payer API
Manual Entry
↓  Event-Driven Message Bus  ↓
AI Intelligence Layer
Clinical Knowledge Agent
NCCI / MUE Validation
LCD / NCD Enforcement
Fraud Pattern Detection
Appeal ROI Engine
↓  AI Multi-Agent Debate → Consensus Decision  ↓
Decision & Audit
Pre-Submission Scorer
ATE Audit Trail (SHA-256)
Litigation Export
Denial Analyzer
Appeal Writer
↓                                                    ↓
🏥 Payer Portal
Adjudication · Audit · Analytics
🏢 Provider Portal
Denial Intelligence · ROI · Appeals
Python 3.12+ / FastAPI
Relational + Vector Search
AI Multi-Agent Reasoning
Vue.js / TypeScript
Docker / Cloud-Native
FHIR R4 · X12 EDI · HL7
Competitive Differentiation

A new category of claims intelligence.

ARIA is the only platform operating on both sides of the claims transaction — with payer tool attribution, ROI-ranked appeal triage, systematic denial detection, statistical fraud flagging, and a closed Bayesian learning loop. No competitor combines all of these on a single auditable platform5.
CapabilityARIAAthenaAdonis
Payer-side adjudicationCore platformNot offeredNot offered
Provider-side denial recoveryFull denial intelligence pipelineBilling-native, post-submissionPost-submission worklist
CARC / RARC payer tool attribution16 payer tool signaturesNot offeredNot offered
Systematic denial detection + legal escalationThreshold-based, DOJ cross-referenceNot offeredNot offered
Appeal ROI triage (FIGHT / WRITE-OFF / ESCALATE)MGMA 2024 benchmarks4Not offeredBasic worklist priority only
ATE audit trail — cryptographic tamper-evidenceSHA-256, 7-year, litigation-readyNot offeredNot offered
AI Multi-Agent Debate consensusVerified — no single-model decisionsNot documentedNot documented
NCCI / MUE enforcement depth1.35M+ edit pairs enforcedRules engine — pre-submissionLimited post-submission
LCD / NCD coverage enforcement1,073 LCD + NCD policies2Available via athenaOne EHRNot offered
Fraud / upcoding early detection (pre-RAC)Statistical outlier detectionNot offeredNot offered
Bayesian learning from appeal outcomesContinuous — 30-sample thresholdNot documentedNot documented
Pre-submission claim scoringIn active build1EHR-native rules engine (athenaOne)Post-submission only

5 Based on publicly documented capabilities for Athena Health (athenaOne) and Adonis as of Q1 2026. Subject to change.

Compliance & Trust

Built audit-ready from day one.

ATE — Accountability, Traceability, Explainability — is ARIA's architectural foundation, not a compliance layer bolted on after the fact. Every AI decision carries a SHA-256 hash, a full agent reasoning chain, and a permanent 7-year audit record. Any decision is reproducible and defensible in court, regulatory review, or payer audit.
🔐
SHA-256 Decision Hashing
Every adjudication decision is cryptographically hashed. Tamper-evidence for litigation support and regulatory audit.
📜
7-Year Audit Trail
Complete chain-of-custody for every claim decision. Meets CMS 7-year retention requirement. Court-ready litigation export on demand.
🏥
HIPAA Technical Safeguards
AES-256 encryption at rest, TLS in transit, PHI stripped from AI prompts, role-based access control throughout.
✅
SOC 2 Type I In Progress
Active SOC 2 Type I certification. Security scanning (Bandit, Trivy, Semgrep) embedded in CI/CD pipeline.
🧠
Explainable AI Decisions
Full agent reasoning chain on every decision. No black-box outputs — every recommendation carries an evidence narrative.
Business Case

Estimate your denial recovery potential.

Based on MGMA 2024 benchmarks — 35% average appeal win rate, $75 appeal admin cost4. ARIA's ROI engine targets only the claims worth fighting, eliminating admin spend on write-offs while maximizing recovery on winnable denials. Adjust inputs to match your volume and payer mix.

Appeal ROI Estimator

$0
Current Monthly Recovery
$0
ARIA-Optimized Recovery
$0
Annual Revenue Uplift
$0
Annual Admin Cost Saved

4 MGMA 2024: 35% average win rate, $75 admin cost/appeal. Individual results vary. Estimate only.

Getting Started

From contract to live in weeks.

ARIA deploys alongside your existing RCM infrastructure — no rip-and-replace required. You keep your current systems running while ARIA runs in shadow mode, builds trust through agreement data, then expands automation tier-by-tier as performance is validated. Five steps from kickoff to full production.
1
Discovery Call
Map your denial categories, payers, and volume. Identify highest-value CARC codes to target first.
2
Data Onboarding
Connect ERA/835 feed or upload historical denial data. ERA, CSV, API — any format works.
3
Configuration
Set automation thresholds, audit rates, and payer rules via configuration. No code changes required.
4
Pilot & Validate
Run ARIA alongside your existing process. Compare AI recommendations vs. human decisions. Build trust with data.
5
Scale Automation
Expand automation tiers as confidence data accumulates. Lower thresholds as AI accuracy is proven.
The ARIA Confidence Ramp

Start in shadow. Scale with confidence.

No health plan or RCM company should hand live adjudication to an AI platform on day one. ARIA's three-phase deployment methodology builds verified trust before expanding automation — with clear, data-driven graduation gates at Day 30 and Day 90. Every human override in shadow mode trains the model on your actual claim population.
👁️
Phase 1
Days 1–30 · Shadow Mode
ARIA Watches.
Humans Decide.
ARIA processes every claim and produces a full recommendation — decision, confidence score, agent reasoning chain. Your team makes the actual decision. ARIA's output is logged but never actioned. Zero risk to live operations.
ARIA roleObserve only
Human role100% decisions
Key outputAgreement baseline
Risk to opsZero
🏛️
Phase 2
Days 31–90 · Supervised
ARIA Acts.
Humans Audit.
Blue-tier (90–100%) claims begin auto-processing. Every auto-approved claim is sampled for human audit. Agreement rates, override patterns, and edge cases tracked. Thresholds expand tier-by-tier as accuracy is validated in your claim mix.
ARIA roleBlue tier auto
Human roleAudit + override
Key outputTier expansion data
Target automation40–60%
🚀
Phase 3
Day 90+ · Full Automation
ARIA Scales.
Teams Focus.
Blue through Orange tiers auto-process with configurable audit sampling. Yellow and Red route to human review — now a fraction of total volume. Your team focuses on complex cases, appeals, and systematic patterns that actually need judgment.
ARIA roleBlue–Orange auto
Human roleYellow / Red queue
Key outputContinuous learning
Target automation~96%†
100% 75% 50% 25% 0% ▲ ARIA Automation ▼ Human Decisions PHASE 1 — SHADOW · Days 1–30 PHASE 2 — SUPERVISED · Days 31–90 PHASE 3 — FULL · Day 90+ Graduation ≥95% agree Graduation Tier validated ~96% Day 1 Day 15 Day 30 Day 60 Day 90 Day 120 Steady ARIA Automation Rate Human Decision Rate Phase Graduation Gate Thresholds configurable per deployment
📊
Phase 1→2 Gate: Agreement Rate
ARIA shadow recommendations must match human decisions at ≥95% on Blue-tier claims over a rolling 30-day window before supervised automation begins. Agreement data surfaced in real time.
🎯
Phase 2→3 Gate: Tier Validation
Each tier (Blue→Green→Orange) is validated independently before expanding automation. Override patterns, audit findings, and edge cases inform threshold calibration for your specific claim mix.
🔄
Continuous: Learning Loop Active
Every human override in Phases 1 and 2 feeds the Bayesian learning model. By Phase 3, ARIA has been trained on your actual claim population — not generic benchmarks. Accuracy improves continuously.
Ready to see ARIA?

Request a live demonstration.

See ARIA process real denial scenarios — NCCI bundling, E&M re-leveling, systematic PXDX clusters, and fraud early detection — with live payer tool attribution, ROI scoring, and AI-generated appeal guidance. Payer and provider demos available independently.
Request Payer Demo → Request Provider Demo →

HIPAA BAA provided · SOC 2 Type I in progress · BCBSNC pilot engagement available