Claims Automation Pipeline¶

Overview¶

BrainSAIT's claims automation pipeline transforms manual revenue cycle processes into intelligent, AI-powered workflows. This document describes the architecture, components, and implementation of our automation platform.

Pipeline Architecture¶

graph LR
    A[Data Ingestion] --> B[Validation]
    B --> C[AI Processing]
    C --> D[NPHIES Submission]
    D --> E[Response Handling]
    E --> F[Analytics]

Pipeline Stages¶

Stage 1: Data Ingestion¶

Sources: - Hospital Information System (HIS) - Electronic Medical Records (EMR) - Practice Management System (PMS) - Excel uploads - API integrations

Formats Supported: - FHIR R4 bundles - HL7 v2 messages - CSV/Excel files - PDF documents - Custom APIs

Capabilities: - Multi-format parsing - Real-time streaming - Batch processing - Error handling

Stage 2: Validation Layer¶

Pre-Submission Checks:

Business Rules¶

• Patient eligibility verification
• Prior authorization validation
• Timely filing compliance
• Benefit coverage check
• Network status verification

Data Quality¶

• Required field completeness
• Data type validation
• Format standardization
• Duplicate detection

Coding Validation¶

• ICD-10-AM accuracy
• CPT/HCPCS validity
• Modifier appropriateness
• Bundling/unbundling rules
• Code-to-code logic

Validation Output:

{
  "status": "valid|invalid|warning",
  "errors": [],
  "warnings": [],
  "suggestions": [],
  "confidence": 0.95
}

Stage 3: AI Processing¶

ClaimLinc Analysis¶

Functions: 1. Risk Scoring - Predict rejection probability 2. Code Suggestion - Recommend optimal codes 3. Documentation Review - Identify missing info 4. Payer Optimization - Apply payer-specific rules

Machine Learning Models:

DocsLinc Processing¶

Capabilities: - OCR for scanned documents - NLP for clinical notes - Entity extraction - Structured data output

Stage 4: NPHIES Submission¶

Submission Process:

1. Bundle Generation
2. Create FHIR Claim resource
3. Include Coverage reference
4. Add supporting information

5. Attach documents

6. Authentication

7. mTLS certificate
8. OAuth 2.0 token

9. Provider credentials

10. API Call

    POST /claim-submit
    Content-Type: application/fhir+json
    Authorization: Bearer {token}
    

11. Response Handling

12. Parse ClaimResponse
13. Extract adjudication
14. Log transaction

Retry Logic: - Exponential backoff - Max 3 retries - Circuit breaker pattern

Stage 5: Response Handling¶

Response Types:

Rejection Handling: 1. Classify rejection type 2. Generate correction recommendations 3. Queue for resubmission 4. Notify relevant staff 5. Track resolution

Stage 6: Analytics & Reporting¶

Real-Time Dashboards: - Submission volume - Acceptance rates - Rejection patterns - SAR recovery

Reports: - Daily submission summary - Weekly denial analysis - Monthly performance review - Payer comparison

KPIs Tracked:

Technical Implementation¶

System Architecture¶

graph TB
    subgraph "Ingestion Layer"
        A[API Gateway]
        B[File Processor]
        C[Stream Handler]
    end

    subgraph "Processing Layer"
        D[Validation Engine]
        E[AI/ML Services]
        F[FHIR Generator]
    end

    subgraph "Integration Layer"
        G[NPHIES Connector]
        H[Payer APIs]
    end

    subgraph "Data Layer"
        I[Claims Database]
        J[Analytics Store]
    end

    A --> D
    B --> D
    C --> D
    D --> E
    E --> F
    F --> G
    G --> H
    D --> I
    E --> J

Technology Stack¶

• Backend: Python, Node.js
• AI/ML: TensorFlow, PyTorch
• Database: PostgreSQL, MongoDB
• Queue: Redis, RabbitMQ
• API: FastAPI, GraphQL
• Infrastructure: Kubernetes, Docker

Integration Points¶

HIS/EMR Integration¶

Cloudpital EMR Integration¶

BrainSAIT provides native integration with Cloudpital's cloud-based EMR system, enabling seamless claims automation:

Integration Architecture:

graph LR
    A[Cloudpital EMR] --> B[BrainSAIT API Gateway]
    B --> C[ClaimLinc Validation]
    C --> D[NPHIES Submission]
    D --> E[Response to Cloudpital]

Real-Time Data Sync: - Automatic encounter capture from Cloudpital - Real-time charge posting and validation - Bi-directional claim status updates - Integrated denial management workflow

Pre-Built Cloudpital Connector:

from brainsait.integrations import CloudpitalConnector

# Initialize Cloudpital connection
cloudpital = CloudpitalConnector(
    api_endpoint="https://api.cloudpital.com",
    credentials=credentials
)

# Auto-fetch unbilled encounters
encounters = cloudpital.get_unbilled_encounters(
    date_range="last_7_days"
)

# Process through BrainSAIT pipeline
for encounter in encounters:
    claim = claim_linc.process_encounter(encounter)
    if claim.validation_score > 0.95:
        cloudpital.submit_to_nphies(claim)

Benefits of Cloudpital Integration: - ✅ Zero manual data entry - ✅ Real-time claim validation - ✅ Automated coding suggestions - ✅ Integrated denial workflow - ✅ 98%+ clean claim rate

Generic HIS/EMR Integration

For non-Cloudpital systems, we support standard methods:

Methods: - HL7 FHIR R4 - HL7 v2 ADT/SIU - Direct database - File exchange

Data Elements: - Patient demographics - Encounter details - Diagnoses - Procedures - Charges

Payer Integration¶

Bupa Arabia: - Real-time eligibility - Prior authorization - Claims submission

Tawuniya: - Benefit verification - Claim status inquiry - ERA retrieval

GlobeMed: - TPA portal integration - Utilization management - Care coordination

Deployment Options¶

Cloud Deployment¶

• AWS, Azure, or GCP
• Kubernetes orchestration
• Auto-scaling
• High availability

On-Premise¶

• Docker containers
• Local database
• VPN connectivity
• PDPL compliance

Hybrid¶

• Sensitive data on-premise
• Processing in cloud
• Secure tunnels

Security & Compliance¶

Data Protection¶

• Encryption at rest (AES-256)
• Encryption in transit (TLS 1.3)
• Key management (HSM)

Access Control¶

• Role-based access
• Multi-factor authentication
• Audit logging

Compliance¶

• PDPL requirements
• HIPAA alignment
• CCHI standards

Performance Metrics¶

Related Documents¶

• Claim Lifecycle
• ClaimLinc Agent
• NPHIES API Reference
• DevOps CI/CD
• Cloudpital Integration - Complete integration guide
• Cloudpital RCM - Revenue cycle features

Last updated: November 2025