Five AI agents. One defensible decision.
SimplifyHealthCare runs every claim through a supervisor-led team of specialist AI agents — an Adjudicator orchestrating Policy, Bill, Clinical and Fraud specialists — grounded in your own policies and SOPs via retrieval. The result: faster payouts, lower leakage and an audit trail your medical board will defend.
Built for the entire claim lifecycle
Explore all modules →Multi-agent adjudication
A LangGraph-style Adjudicator supervises four specialists — Policy, Bill, Medical and Fraud — with a full audit trace of every thought and tool call.
RAG-grounded reasoning
pgvector-backed retrieval over policies, SOPs, clinical guidelines and historical precedents — no hallucinated rules.
Fraud, waste & abuse
Graph models surface collusion rings, phantom billing and upcoding before payout — with provider risk scores.
Cost optimization
Line-by-line bill review and contract-aware repricing across hospital networks and tariff schedules.
Explainable AI
Every decision ships with the clauses, line items and evidence the model used — defensible to regulators and members.
Analyst workflow
Accept, override, query and request evidence in one click. AI drafts the message to the hospital or member for you.
A supervisor orchestrates five specialists
Instead of one monolithic prompt, each claim is reviewed by purpose-built agents that share retrieved evidence and reconcile through a supervisor — the same pattern used in modern agentic frameworks like LangGraph.
Reads the member's policy, riders, exclusions and waiting periods. Cites the exact clause behind every call.
Walks every line item against tariffs and package rates. Catches unbundling, duplicates and upcoding math.
Validates clinical coherence — diagnosis, procedure, length of stay and standard of care.
Cross-checks provider history, member patterns and graph signals for collusion and phantom billing.
A supervisor orchestrates the specialists, reconciles findings and writes the final recommendation.
One platform. Twelve modules.
From intake to payment — and everything regulators ask about in between.
Built for every side of the claim
Cut loss ratios with consistent, defensible adjudication at scale.
Run multi-tenant books with shared AI and per-client policy isolation.
Get cleaner claims out the door and fewer denials coming back.
We replaced a 40-page checklist with a 12-second AI decision — and our medical board can still trace every call back to a clause.
The fraud graph flagged a collusion ring in week two that our SIU had been chasing for nine months.
See your next claim adjudicated in 12 seconds.
Open the platform, run the multi-agent supervisor on a sample claim, and follow every step of the reasoning.