ENIGMA — Document Intelligence & Claims Automation

From scanned
document to
payment decision.

ENIGMA is the AI intelligence layer between claim receipt and payment release — digitising documents, applying 7.5M+ clinical rules, and identifying fraud before any rupee is paid.

ENIGMA — AI Document Intelligence
Claim #INS-2024-8821
Apollo Hospital, Mumbai · IP Cashless
01 / 05
Document Intake
Documents received for AI processing
Discharge Summary
Queued for AI processing
7.5M+
Clinical rules
High
STP rate
Fast
Per-claim speed
10+
FWA triggers
The Challenge

Documents are the
weakest link in claims.

Claims teams process thousands of unstructured documents daily — manually. Fraud slips through, non-payables go undetected, and turnaround times suffer.

Most
Document Chaos
claims arrive unstructured
Unstructured Formats
Scanned PDFs, handwritten forms, and fax submissions — all requiring separate manual workflows.
Complex Provider Tariff Documents
Complicated provider tariff documents need to be digitised, structured, and applied automatically for Straight-Through Processing.
Inconsistent Data
Non-standard coding and missing fields make automated validation impossible at scale.
Significant
Fraud & Leakage
leakage from missed non-payables
Document Tampering
Altered bills and forged discharge summaries pass manual review without AI-assisted checks.
Duplicate Billing
Same service billed multiple times or across providers — invisible without cross-claim intelligence.
Missed Non-Payables
Personal expenses and policy exclusions slip through manual review undetected, every day.
Hours
Operational Burden
average manual processing time
Manual Queues
Each claim moves through document, clinical, and fraud reviewers — in silos, in sequence.
Delayed Decisions
Cashless approvals taking many hours — friction for members, disputes with providers.
Rising Costs
Growing claim volumes with static headcount — cost-per-claim rises every quarter.
Recognise these problems? See how ENIGMA solves each one.
A 30-minute demo built around your document types, languages, and fraud patterns.
Book a Demo
What is ENIGMA

The intelligence layer between documents and decisions.

ENIGMA combines Document-Level Intelligence with a Clinical Rule Engine — delivering true end-to-end claim processing automation and FWA identification. From the moment a claim arrives to final adjudication, ENIGMA eliminates manual touchpoints, detects fraud, and ensures every rupee is paid right.

Document Intelligence

AI-powered categorisation, entity extraction, and digitisation of all OP, IP, or Wellness claim-related documents.

4 languages· English, Arabic, Urdu, Hindi

Medical Rules Engine

The industry's most robust deterministic layer. Hard-logic clinical validation across millions of medical standard protocols.

7.5M+· AMA-aligned clinical rules

FWA & Waste Detection

Identifies document tampering, forgery, syndicate patterns, and 40+ clinical abuse triggers — automatically.

40+· clinical abuse triggers

Insights & Co-Pilot

Real-time dashboards, tariff benchmarking, and an AI co-pilot that recommends final payable amounts.

Real-time· dashboards & benchmarking
Claims Intelligence Workflow

End-to-end. Automated.
Every claim, every time.

Five intelligent stages from claim receipt to final decision — no manual touchpoints in the standard flow.

Claim Ingest
Multi-Format Claim Ingestion

Every claim enters ENIGMA — reimbursement or cashless, digital or scanned — automatically normalised across all formats from the moment of receipt.

How — Accepts EDI, PDF, image, email, and API submissions. Every document auto-classified and queued for AI processing without manual routing.
Impact — Zero manual sorting. Every claim enters the intelligence pipeline automatically, regardless of source, format, or language.
Rapid · Ingest time
AI Digitisation
AI Digitisation & Categorisation

AI reads, categorises, and extracts structured data from every claim document — discharge summaries, bills, lab reports, prescriptions — in any format or language.

How — Deep document AI trained on millions of insurance documents. Extracts entities, identifies document type, auto-codes ICD/PCS, and flags non-payable items.
Impact — Every claim fully digitised in seconds. No manual data entry. ICD/PCS codes applied automatically. Non-payables surfaced before adjudication.
Multi-language · English · Arabic · Urdu · Hindi & more
Rule Validation
Clinical Rules Engine — 7.5M+ Rules

ICD 9, ICD 10 AM/CM, CPT, and CDT code validation, condition-specific adjudication logic, and policy-linked coverage rules applied across every claim in milliseconds.

How — Includes sublimit enforcement, room capping, coverage exclusions, and condition-specific pathways for Cataract, Maternity, and surgical procedures.
Impact — Billing errors, coverage violations, and coding inconsistencies caught before FWA scoring — no human reviewer required for standard validations.
7.5M+ · AMA-aligned rules
FWA Scoring
Document Fraud & Abuse Detection

ENIGMA runs 10+ document-level FWA triggers and 40+ clinical abuse checks — covering tampering, forgery, provider abuse, inflated billing, and syndicate patterns.

How — Risk-scored alerts generated per claim. High-risk claims auto-escalated to investigation. Confirmed fraud auto-rejected with full audit trail.
Impact — Document fraud, ghost billing, and abuse patterns identified and acted on before any payment is released.
10+ · Doc-level FWA triggers
Auto-Adjudication
Decision Support & Auto-Adjudication

Clean claims are auto-adjudicated with a final payable recommendation. Complex cases surface to human reviewers with full AI rationale, evidence, and deduction breakdown.

How — Claims Co-Pilot reconciles bills, deducts non-payables, and recommends final payable. Human reviewer confirms or overrides with complete audit trail.
Impact — High straight-through processing rate. Human reviewers focus only on exceptions — not routine claims. Turnaround time significantly reduced from manual baseline.
High · Straight-through processing
Business Outcomes

Measurable impact from deployment.

Built by practitioners. Proven across live deployments with health insurers and TPAs in India, UAE, and Saudi Arabia.

Fast
Claims Processing Time
Dramatically reduced from manual baseline
High
Straight-Through Processing
Claims auto-adjudicated without manual touch
40+
Fraud Triggers Automated
Document and clinical abuse patterns covered
Near-zero
Missed Non-Payables
Compared to high manual review miss rate
Significant
Cost Reduction Per Claim
Operational savings at scale with ENIGMA
See these outcomes applied to your claims portfolio.
Our team builds the ROI case around your actual claim volumes and document mix.
Book a Demo
20+
Years experience — model training on practitioner data
Live on 5Mn
Annualised claims
7.5M+
Clinical rules
Multi-language
Support

See ENIGMA processing your claims in real time.

Our team will walk you through a demo built around your document types, languages, and fraud patterns — not a generic slide deck.

Book a Personalised Demo
No commitment required
Tailored to your document types
Response within 24 hours