AI solutions
20x your team's impact with AI Agents
Our AI Agents enable automated workflows that process routine clinical case reviews, enabling health plan claims teams to move faster and deliver deeper savings.
Trusted across the entire claims lifecycle
Deeper insights. Better outcomes.
Purpose-built for health plans, our AI platform helps claims teams provide truly defensible findings with an extremely low appeals rate. We’ve achieved 97%+ accuracy across all client implementations.
Step 01
Document digitization
Our AI Agents transform PDF files and scanned images of all sizes into actionable data assets.
Step 02
Smart evaluation
Working from your clinical configuration, our Agents reason against your medical records, policy guidelines, and relevant clinical criteria.
Step 03
Transparent recommendations
Every recommendation includes a clear clinical rationale and traceable source citations, with links back to medical records and policy documents.
Step 04
Human validation
Human clinicians are always at the helm. Your clinicians validate each recommendation, ask final questions, and complete the claim.
Build a custom AI Agent
Uniquely built for your organization, fine-tuned with your clinical criteria and policies.
Utilization Management Agents
Streamline approval decisions with made-for-you AI that applies clinical guidelines consistently across all review types.
Prospective, concurrent, and retrospective reviews
Emergency department reviews - EMTALA and prudent layperson
Level of care reviews
High-cost drug and specialty pharmacy reviews
Payment Integrity Agents
Identify clinical validation opportunities and reduce payment errors with an AI Agent that thoroughly analyzes documentation against evidence-based standards.
DRG clinical validation (sepsis, cardiovascular conditions, respiratory conditions, and more)
Medical necessity reviews
Readmission reviews
Short stay reviews
Appeals Agents
Transform your appeals department with the support of AI to evaluate clinical documentation, apply relevant policies, and draft evidence-backed responses.
Pre- and post-service appeals
Emergency service appeals
Level of care appeals
DRG & coding appeals
Readmissions Agent
Evaluate readmissions for clinical appropriateness and uncover preventable cases automatically.
DRG Agent
Optimize diagnostic related groups classification with high-precision AI analysis.
Emergency Dept. Reviews
Streamline emergency department throughput and review workflows in real-time.
Appeals Agent
Cut appeals at the source and resolve the rest with precision using intelligent clinical automation.
Prior Auth Agent
Automate the complex prior authorization process with clinically-aware decisioning.
Smart triage that lets your clinicians do their most valuable work
Our AI agents review clinical cases 20x faster than human clinicians, routing clear approvals for immediate processing while flagging complex cases. That frees up your clinicians to focus their time and expertise where it matters most.
See how Alaffia's AI can transform your claims operations
Time spend on 100 reviews
Existing manual process
100 hours
With AI agents
8 hours
Minutes per case review
Existing manual process
60 minutes
With AI agents
10 minutes
Daily case review capacity per FTE
AI trust and safety
Privacy, security, and compliance are built into every layer of our solutions. We adhere to HITRUST, SOC-II Type II, and HIPAA security standards to keep member and payer data private and secure.
Every recommendation includes a clear clinical rationale and traceable source citations, with links back to medical records and policy documents.
To ensure adherence to your organization’s specificdata governance requirements, we establish andimplement custom governance controls.
All data stored within our platform is encrypted intransit and at rest, with 256-bit encryption to protect confidentiality and privacy.
Why leading health plans partner with Alaffia
“Alaffia opened our eyes to bigger savings and recoveries than we ever thought possible. The dollars they unlock and services they deliver are unlike anything I’ve seen from previous vendors.”
Leading Regional Health Plan
VP of Operations
“Their platform provides a level of visibility we simply didn't have before. It’s transformed how we manage our payment integrity processes across the entire organization.”
Regional Health Plan
VP of Operations
“The speed of implementation and the immediate ROI was impressive. Alaffia's team feels like an extension of our own, dedicated to our success every step of the way.”
Regional Health Plan
Head of Payment Integrity
“Alaffia is setting a new standard for how data and AI can be used to protect Medicaid resources while ensuring patients receive the care they truly need.”
US Medicaid
Dr. Andrey Ostrovsky, Former CMO
Drive health plan affordability with Alaffia
Discover how our clinical review platform drives real savings for your plan.
Learn more