Pillar One · Settlement Integrity
Decide Before the Money Moves.
Pre-settlement attestation and retroactive scan in a single pillar. Every claim verified before it settles. Every historical claim re-examined with court-ready evidence. The Verdict Engine runs the same 500+ checks whether the claim is in-flight or five years old.
Payment integrity has been a one-direction problem: pay first, recover later. JIL operates in both directions. Pre-settlement attestation intercepts claims at the moment of adjudication and returns a binding verdict before money moves. Retroactive scan re-examines every settled claim in the book of business and produces sealed evidence for each finding. The same Verdict Engine. The same evidentiary standard. Two surfaces, one pillar.
Business use
Built for payment integrity at institutional scale.
Health plans, MACs, UPICs, MFCUs, and payment integrity teams need a verdict before money moves. Existing systems detect after settlement. JIL detects before settlement, and re-examines retroactively against the same evidentiary standard.
Two surfaces, one engine
Pre-settlement and retroactive scan, same Verdict Engine.
Real-time verdict
API integration with the claims engine. Each claim passes through 175 deterministic checks before adjudication. Verdict returned in under 2 seconds at the 95th percentile.
Historical re-examination
Re-scans every settled claim in the book of business against the same 500+ checks. 100% scanned, not sampled. Findings are sealed individually with the criteria version in force on the date of service.
Court Ready Evidence Bundle
Every finding is sealed as a CREB anchored on CourtChain under FRE 902(13). Self-authenticating, no custodian testimony required.
Explainable verdicts
Reason codes and rule citations travel with every verdict. Not a black box. Appeals can replay against the exact criteria used.
Use cases
Where pre-settlement lands.
Medicare Advantage payment integrity
Pre-adjudication verdict on claim eligibility, medical necessity, and contractor flags.
State Medicaid program integrity
MFCU-aligned attestation for provider, beneficiary, and service-delivery checks.
SIU referral support
Evidence-ready findings routed into the investigator workflow with sealed CREB attached.
CMS & OIG audit readiness
Verifiable record of every check run, criteria cited, and verdict reached. No reconstruction needed.
Retroactive recovery
Re-examine the historical book of business. Each finding sealed individually. Recovery counsel uses the CREB as the evidence record.
Defensible appeals
Reason codes and frozen criteria travel with every verdict. Appeals replay against the actual basis of the original decision.
Workflow architecture
From intake to sealed verdict.
The 175-check engine and the retroactive scan share one workflow. In real time, claims pass through pre-settlement attestation before adjudication. Retrospectively, the same engine re-scans the historical book of business with the criteria version in force on the date of service.
Technical deep dive
The 175-check Verdict Engine.
- Claim header and detail lines (X12 837, NCPDP, EDI)
- Provider master and credentialing
- Beneficiary eligibility and enrollment
- Prior authorization status
- Place of service and date of service
- OIG / SAM / state exclusion lists
- Mortality and identity sources
175 deterministic checks across: identity, eligibility, medical necessity, place-of-service, date-of-service, provider credentialing, exclusion-list status, service-delivery, cost-report, and cross-entity patterns. Each check produces a structured reason code and rule citation.
Verdict is Pass / Review / Block. Risk score, triggered checks, reason codes, criteria citations, and evidence references travel with the verdict. P95 latency under 2 seconds for the real-time API path.
The CREB packages the claim context, check execution log, reason codes, rule citations, exhibits, and a cryptographic timestamp. CourtChain seals the bundle under FRE 902(13). Self-authenticating; no custodian testimony required at trial.
API integration with major claim engines. Snowflake share for batch retrospective scan. Webhook callbacks on verdict change. SIU and recovery routing into existing case management systems.
HIPAA-aligned data handling. Encryption in transit and at rest. Role-based access. Tenant isolation. Audit logging on every verdict and every evidence retrieval. Retention policy configurable per customer.
- Discovery session
- Data source inventory
- Synthetic file review
- Historical retrospective scan
- Real-time pre-settlement pilot
- SIU / recovery routing
- Production deployment
- Ongoing monitoring
What this is not
Scope, plainly.
- Not a claim engine replacement
- Not a final adjudication of medical necessity
- Not legal advice
- Not contingency-priced - flat per-claim pricing
- Not a black box - reason codes and rule citations are visible on every verdict
Verify the claim before the money moves.
Brief your payment integrity lead. We will walk the 175-check engine, the CREB evidence model, the pricing, and the integration path with your claim engine.
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