Alaffia Health provides a purpose‑built AI platform that automates routine clinical case reviews for health‑plan claims, appeals, utilization management, and payment integrity. The system ingests scanned and electronic records, applies policy and clinical criteria, and delivers transparent, citation‑backed recommendations with >97% accuracy, boosting review throughput up to 20× while remaining HIPAA, SOC‑II Type II, and HITRUST compliant.
Funding
$25K raised to dateRaised to date based on public sources. This may differ from the amount the company actually raised and is based only on what is publicly available on the internet.
HAFounders
Product
Problem
Health plans incur billions of dollars each year in improper payments and administrative inefficiencies due to manual clinical claim reviews, appeals processing, and utilization management. These labor‑intensive workflows lead to high error rates, slow throughput, and elevated operational costs.
Solution
Alaffia Health delivers a purpose‑built AI platform that automates routine clinical case reviews across claims, appeals, utilization management, and payment integrity functions. Proprietary AI agents ingest scanned documents and electronic records, apply policy guidelines and clinical criteria, and generate transparent recommendations with citations for human validation. The system integrates with existing payer IT stacks within 30 days, maintaining HIPAA, SOC‑II Type II, and HITRUST compliance. By routing clear‑cut cases for automatic approval and flagging complex ones for clinician review, the platform boosts review throughput by up to 20 × while achieving > 97 % accuracy and defensible outcomes. This enables health‑plan teams to focus on high‑value decisions, reduce appeal rates, and capture measurable cost savings.
Target Audience
Primary customers are health‑plan claims, payment‑integrity, utilization‑management, and appeals teams that need to accelerate clinical review processes while maintaining regulatory compliance.
Features
- AI agents that digitize PDFs and scanned images, converting them into structured, searchable data
- Clinical reasoning engine that cross‑references medical records, policy rules, and evidence‑based criteria to produce claim recommendations
- Transparent output with rationales and source citations for each decision, supporting human validation
- Customizable agents for specific workflows such as utilization management, payment integrity, and appeals processing
- Seamless integration with existing payer systems via APIs, with deployment in ≤30 days and no workflow disruption
- Enterprise‑grade security: end‑to‑end 256‑bit encryption, SOC‑II Type II, HIPAA, and HITRUST compliance
- Real‑time performance metrics showing 20 × increase in case‑review throughput and > 97 % accuracy