Health plan operations, re-architected for AI
We engineer the intelligence layer around your core—integrated, governed, and traceable—so AI can run in claims and clinical work without you losing control.
12 of Top 15
US health plans
3 of Top 5
Blue (BCBS) plans
100M
lives touched across the value chain
Avasant RadarView™
Leader in Healthcare Payer Business Process Transformation
Everest Group PEAK Matrix®
Leader in Healthcare Payer Intelligent Operations
NelsonHall NEAT
Leader in Healthcare Payer Agility & Innovation
Everest Group
Front-runner in the Generative AI Healthcare Payer Market
NelsonHall
Leader in Healthcare Payer Operational Transformation
ISG Provider Lens™
Leader in Payer Transformation on Healthcare Digital Services
Everest Group PEAK Matrix®
Leader in Healthcare Payer Business Process as a Service Solutions (BPaaS)
Why IT Matters NOW
Making your operation ready for agents
Modernizing the core administration platform is necessary, but it doesn't make the operation around it AI-ready. That work still runs on brittle integrations and siloed data, point-vendors are circling claims, prior auth, and payment integrity, and CMS interoperability and electronic-PA mandates keep adding engineering load. The hard part isn’t the model—it’s an estate agents can’t yet operate safely.
The automation mandate
$258B
The cost mandate is set; the gap is execution
Automation took $258B out of US healthcare admin in a single year—yet manual work still consumes up to a quarter of total spend. The pressure to close that gap lands on your stack.
CAQH Index, 2025
Fragmented data
50%
AI is only as good as the data it can reach
Member, claims, and provider data sit in silos—and bad provider data alone drives half of all denials. Without connected, real-time context, AI can’t make a decision you’d stand behind.
Experian Health, Sep 2025
The scaling wall
#1
Pilots that can’t reach production
Explainability, PHI security, and auditability, not model availability, are the primary barriers to scaling AI beyond the proof-of-concept stage. The hard part is governing it in regulated work.
Everest
We don’t bolt AI onto the claim. We re-architect the health plan for AI and run it, so intelligence actually operates.
Proof in production
Named outcomes, inside real health plans
Platforms we built where building was the right call and operations we run to the number. A selection across claims, intake, and payment.
Digital intake | Marquee platform
Healthcare Digital Intake AI
Live across leading US health plans. Vision-language models classify and extract from claims and non-claims documents—replacing OCR preprocessing and manual review.
95%+
field-extraction accuracy
80%+
straight-through processing
~50%
lower cost per intake
Claims operations | Top US health plan
Claims and provider-data transformation
Gen-AI and automation across claims adjudication and provider operations at a top US payer.
$100M+
operational cost reduction
$70M+
late-payment interest avoided
$120M+
overpayments reduced
Medicaid | State fiscal agent
Medicaid claims modernization
Gen-AI and automation to modernize Medicaid claims, provider, and member services for a US state fiscal agent.
99.51%
business-process accuracy
0.69 days
e-claims processing time
$5.3B
annual claims payments facilitated
Kairos the operating system
From the claim to the member, one connected system
Claims, prior authorization, and member and provider operations are connected on one operating system, so every agent acts with the full picture and every decision remains traceable. The durable core is the middle three layers, while your systems and agents sit at the edges.
The platform is vendor-agnostic and continuously compounds intelligence. The health plan's adjudication judgment and decision traces become durable intellectual property, portable across any core platform or model.
The platform is vendor-agnostic and continuously compounds intelligence. The health plan's adjudication judgment and decision traces become durable intellectual property, portable across any core platform or model.
05
AI-native operations: Agents
Claims, prior authorization, payment integrity, appeals, and provider dispute agents come preloaded with domain intelligence and an agent governance package that includes audit trails, override controls, and explainability.
Varies by plan
04
Domain Intelligence: Domain Harness
A Decision Logic Library for your most complex calls (adjudication, COB, subrogation, PA), an Exception Pattern Repository of 100+ payer exception types, Should-vs-Did scoring, and a Failure-Point Library—encoded, not documented.
Core
03
Organizational context: Intelligent Context Framework (ICF)
The ICF captures what happened through five registries: Session and Entity Context for member, provider, and claim 360 views; immutable Decision Traces; Execution Signals that expose Should-vs.-Did gaps; and cross-client Domain Benchmarks.
Core
02
Operations intelligence: Sensors
Operations Intelligence captures what's happening in flight through five sensor classes: process mining, task mining, conversation intelligence, knowledge mining, and document intelligence across HCFA and UB-04 forms.
Core
01
Raw data and transactions: Systems of record
Core administration and claims platforms, such as HealthEdge, Facets, and QNXT, are connected through a domain-centric API library and canonical data model. The platform supports real-time event streaming, audit and lineage tracking, and pre-built propensity models for LPI, FWA, provider risk, and denials.
Varies by plan
Where the signal becomes memory
Learn about the Intelligent Context Framework
What we engineer for payers
From the core platform to the member—the whole operation
Core admin and claims platform modernization
~50% tech debt eliminated | 225+ apps rationalized
We modernize and integrate the core admin and claims estate—EDI/X12, enrollment, provider and member systems—so agents can access it safely and in real time.
Systems, application and data engineering
Digital intake and document intelligence
98.5% on HCFA | 98.7% on UB-04
We turn mail, fax and portal documents—HCFA, UB-04, dental and correspondence—into structured, classified data with vision-language models, not brittle OCR.
Sensor and operations intelligence
Claims adjudication intelligence
30% claims cost ↓ | 33% FTE effort saved
We encode benefits and adjudication policy into the harness so standard claims resolve straight through, while complex claims are reasoned to a decision with a documented rationale.
Domain harness engineering
Payment accuracy, payment integrity and FWA
$20M+ late-payment interest avoided | $120M+ overpayments reduced
We use a propensity engine to prevent late-payment interest before the clock runs out, surface pre-pay overpayments, and flag fraud, waste and abuse—each with the evidence trail to defend it.
Sensor and operations intelligence
Prior authorization and utilization management
Routine approvals in minutes—built for CMS-0057
We orchestrate clinical guideline checks and human review for the CMS-0057 era, delivering routine approvals in minutes while routing complex cases to a nurse with the evidence pre-assembled.
Agentic Orchestration
Provider data, network and regulated submissions
98% provider-data accuracy | 66% faster appeals TAT
We keep provider data and rosters clean and synchronized across systems, and run regulated intake—appeals, grievances, encounters and 837 submissions—as a traceable pipeline.
Context and knowledge engineering
The payer solutions this powers
The technology above runs behind our healthcare-payer solutions. Explore the ones built for your operation:
Claims optimization
Digital mailroom
Network operations
Member enrollment
Member engagement
Population health
Population health
Population health
Trust & Compliance
Regulatory rigor. By design.
The intelligence layer is engineered to run inside the most regulated payer data environment in the US—on a certified security foundation, with governance and traceability in every workflow, not bolted on after.
HITRUST
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SOC 2 Type 2
ISO 27001
PCI DSS
SSAE 16
HIPAA and HITECH · CMS-0057-F
Compliant in the workflow, not bolted on
Data handling, breach notification, and the CMS electronic-prior-auth rule (effective Jan 2026) are engineered into how the work runs—not reconstructed at audit time.
Progressive trust
Autonomy that’s earned, not assumed
Agents start under human review and graduate to higher autonomy only as evidence earns it—HITL to HOTL to HATL—calibrated to the risk of each task.
Decision traceability
Every decision, reconstructable
An immutable audit log of every agent decision—reproducible for a regulator in seconds—with override controls, lineage, and explainability built in.
full-stack operator
Intelligence That Operates
Where it starts
Operating-model & AI diagnostic
Most payer engagements start with a diagnostic that frames the value at stake before anything is built.
Explore Consulting
The signal
Sensor and operations intelligence
The process mining and document intelligence behind Digital Intake and payment-integrity—including ~$10M in late-payment penalties avoided on one plan’s claims operation.
Explore the capability
How WE Engage
Transform, implement, and operate
Good questions to start with
Do we have to replace our core admin / claims platform?
No. We modernize and integrate what you run—HealthEdge, Facets, QNXT and others—wrapping the core in a clean backbone so agents can reach it safely. We replace only where replacing is genuinely the right call.
How do you keep AI in claims and clinical work compliant?
Compliance is structural. HIPAA-grade guardrails and benefits/clinical policy are encoded in the harness, every decision leaves an auditable trace in the context framework, and agents earn autonomy progressively—so prior-auth and adjudication are audit- and regulator-ready by default.
Is Digital Intake just OCR?
No. It uses patent-pending vision-language models with agentic classification and extraction—~96%+ accuracy across HCFA, UB-04 and dental forms—which removes the preprocessing, rule maintenance, and manual-review cycles legacy OCR depends on.
How is this different from a prior-auth or payment-integrity point solution?
Point tools solve one step and keep the learning. We engineer and operate the whole operation—intake to adjudication to member—and the plan’s judgement compounds as your IP, portable across any core platform or model.
Do you build the AI models yourselves?
We don’t build foundation models from scratch. We select, fine-tune and evaluate domain models on your data as your data services partner—see AI Data Services—and engineer and operate the stack they run in.
INSIGHTS
Latest from the Firstsource team
Insights from the field, real operations, real outcomes, and perspectives from the people making it work in live operations.
Case Study
Building a strong foundation for growth: how a leading dental plan transformed operations with strategic partnership
Discover how a leading dental plan partnered with Firstsource to transform operations, reduce costs, improve CSAT, and enable scalable growth through AI and a hybrid delivery model.
CONTACT US
See where AI changes your cost and risk first
Start with a diagnostic across mortgage, lending, cards and fraud. We’ll frame the value at stake — and the first operation to re-architect — before you commit to anything further.