ClaimGuard NG verifies, adjudicates, and pays health insurance claims from any provider — hospital, clinic, pharmacy, lab, or imaging centre — for any HMO, in one national system. An AI engine checks every claim against 15 fraud and integrity rules before a human ever sees it. A second, fully independent engine watches the clinical data underneath for hypertension, diabetes, pregnancy risk, and medication non-adherence — before they become expensive emergencies.
Claims adjudication and health risk prediction answer different questions, for different audiences. ClaimGuard NG never lets one engine's output quietly become the other's input — whether a claim gets paid is decided on claims data alone.
A regulator, an HMO claims officer, and a hospital records team are not asking the same question. Pick yours.
ClaimGuard NG gives NHIA a single oversight dashboard across every HMO, every provider, and every state — fraud heatmaps, HMO scorecards, and claims velocity, updated as claims move, not in a quarterly report.
Every claim arrives in your queue with eligibility, tariff conformance, and 14 live fraud rules already run — sorted by risk, not by date received, with the evidence trail attached so a decision takes seconds, not a phone call.
The claim form adapts to what you actually do — a hospital admission isn't asked to fit a pharmacy's shape. Submit, and watch your own claim move through verification and validation in real time, the same trace an HMO officer sees.
Every rule the Claims AI can raise is published — the same registry the live engine evaluates against. A sample of what it watches for:
A hospital's EMR, a pharmacy's POS system, or an HMO's core platform shouldn't have to learn ClaimGuard NG's internal data model to talk to it. They speak the formats they already speak — ClaimGuard NG translates.