An AI engine that clears routine claims automatically and routes only the complex ones to people — speed and scale, with compliance built in.
In delivery
Adjudicators reviewed claims by hand — including the high volume of routine, rules-based claims that don't need human judgment. Pisteyo designed a tiered AI engine: routine claims clear automatically while complex cases escalate, and any low-confidence decision routes to a human reviewer. Routine claims clear at machine speed, adjudicators focus on the complex and the exceptional, and every decision stays compliant and auditable.
The organization is a healthcare provider whose claims operations sit at the center of its work: every claim must be adjudicated accurately, paid correctly, and documented for compliance. Day to day, adjudicators work through a large, steady inflow of claims — most routine and rules-based, a smaller share genuinely complex — where the standard for accuracy is absolute.
Adjudicators worked two problems at once. Most appeals arrived through a shared inbox that was hard to de-conflict when several people worked one case; Pisteyo first automated intake so every case is captured and created from its source document. Then automation took over the routine, rules-based claims that once tied skilled people up on repetitive checks — all while accuracy and compliance could never slip.
A staged delivery designed for quality, compliance, and trust — moving from scope to a production-ready capability without disrupting the business.
Mapped the claims lifecycle with the organization's claims and operations leaders, distinguishing routine, rules-based claims from genuinely complex cases (including prior authorization).
Chose a scalable, compliant data foundation, refreshed on a regular cycle.
Designed a tiered AI approach — fast handling for simple adjudications, more sophisticated handling for complex ones — to balance accuracy against cost.
Built in human oversight: any adjudication the AI isn't confident about routes to a secondary human review before it stands.
Standardized the rules and terminology so edge cases are handled consistently.
Validated the architecture with the team, then delivered the foundation first, followed by iterative rollout.
The honest view: every deployment meets real-world constraints. Here is what was hard, and the deliberate choices that kept quality high and risk low.
Every automated decision had to be defensible. Pisteyo built a secondary human-review layer for low-confidence adjudications and a full audit trail from day one.
Prior authorization and supporting-document logic required dedicated working sessions with the organization's subject-matter experts to capture the conditions correctly.
Running every claim through the most powerful handling would be expensive. A tiered design keeps simple claims cheap and reserves sophisticated handling for cases that need it.
Edge cases like duplicate claims needed consistent handling — standardized with updated documentation.
Pisteyo built an auto-adjudication engine that clears routine claims at machine speed while keeping people in control of everything that needs judgment. Routine, rules-based claims that once consumed adjudicator time now clear automatically, returning capacity to the claims team and shortening turnaround for members and providers.
“The biggest benefit for our team was eliminating the manual work of reviewing appeals and creating the cases — the automation handles that for us, plus the routine appeals, and it's working well.”
As confidence grows, the share of claims handled automatically can expand, and the same pattern can extend to adjacent work — prior-authorization triage, payment integrity, and duplicate detection. With clean, structured decisions captured on every claim, the organization gains a foundation for analytics, error detection, and continuous improvement.
The routine, rules-based claims that don't need human judgment. Complex and exception cases go to people.
A tiered approach handles simple claims quickly and escalates complex adjudications for more sophisticated handling, with prior-authorization logic where needed.
Any low-confidence decision routes to a secondary human review before it stands, and every decision — automated or human — is logged for audit.
Intake is automated: appeals are captured and their cases created directly from the source documents, replacing a hard-to-manage shared inbox.
Routine claims clear at machine speed with shorter turnaround, adjudicators focus on complex work, and every decision stays compliant and auditable.
The same operator-led approach — strategy, build, and measured adoption — applied to your workflows.
