ARIA - AI for delegated risk

The AI engine that
reads your DOFRs
and every claim against them.

ARIA (Adaptive Risk & Integrity Auditor) is the layer between your contracts and your claims platform. It codifies the rules your operators have been reading by hand, then audits every claim against them - line by line, in real time or 24 months back.

Four modules.
One source of truth.

01 / Ingest

Pull in what you already have.

DOFRs (PDF, DOCX), EOCs, Benefit Option Grids (XLSX), Risk Matrices, plus claim extracts in 837, UB-04, CMS-1500, or any flat file you can produce.

DOFR.pdf EOC.docx BenefitGrid.xlsx 837.edi

02 / Codify

Translate contracts into rules.

ARIA parses each contract into a versioned, machine-readable rule set - service line, place of service, member attributes, effective dates, carve-outs, sub-cap thresholds, shared-risk pools. Reviewed and signed off by your team.

§3.1 · capitation §4.2 · OOA §7.1 · sub-cap

03 / Audit

Run every paid claim against the codified contract.

Look-back: 24 months of paid claims, line by line, against the rule set in force at adjudication date. Every variance ships with the rule that proved it, the dollar delta, and a confidence score.

Evidence pack Recoupment queue Examiner attribution

04 / Monitor

Catch the next leak before it leaves the door.

Forward-looking: ARIA monitors adjudication in real time, flagging mis-attributed claims pre-payment. EOC and DOFR updates are re-ingested as they happen.

Pre-pay flags Live dashboards EOC change feed

The product, end to end.

Dashboard

Executive view across modules. KPIs, mismatch claims, recovery queue, DOFR library, and configuration defects in one frame.

Every variance comes with the
contract clause that proved it.

No black-box statistics. Every flagged claim ships with:

The claim lineCPT, POS, DOS, billed and paid amounts.
The rule appliedThe exact DOFR section and effective date.
What was paid · what should have beenSide-by-side dollar deltas.
The reattributionWhere the financial responsibility actually belongs.
A confidence scoreSo your team triages high-yield variances first.

Hit "dispute" if you disagree - ARIA logs every decision and learns your team's rulings.

Claim review sample

OOA · misrouted

CLM-104829

CPT 70553 MRI lumbar spine · Professional

POS

22 · Outpatient

DOS

2026-01-01

Paid

$1,842.00

Member home

90011 LA, CA

127.4 mi

Provider

91901 Alpine, CA

Threshold check distance > 30 mi · FAIL

Rule applied §4.2 OOA Carve-Out

Current assigned risk Health Plan

Gabeo's identified risk IPA Risk Pool

Variance + $1,842.00 recoverable

Confidence 94%

Every contract your team has,
codified and versioned.

DOFRs change. Benefit grids drift. ARIA keeps a single living source of truth - versioned by trading partner, by line of business, by effective date.

Per trading partnerOne contract, one rule set. No conflation across plans.
Versioned by effective dateAudits run against the rules in force on DOS, not today.
Side-by-side diffsSee exactly what changed between contract versions.
Operator-reviewedYour DOFR analyst signs off on each rule before it goes live.

DOFR LibraryPacific Valley MSO · sample

25 contracts

Contracts

Live

In review

Rules

411

APC · Health Net

Commercial HMO · 28pp · 13 rules

Live

APC · Anthem Blue Cross

Commercial HMO · 32pp · 14 rules

Live

AlphaCare · Blue Shield CA

Commercial HMO · 30pp · 15 rules

Live

CFC · Anthem Blue Cross

Medi-Cal Managed Care · 41pp · 19 rules

In review

Sits on top of your stack.
Not in it.

ARIA is a system of record for your contracts and an audit layer on your claims. It doesn't replace your claims platform - it makes it honest.

Flat-file friendly

SFTP or secure object storage. CSV, 837, UB-04, CMS-1500. No API contract to maintain on your side.

Platform agnostic

Compatible with HealthRules, EZ-CAP, Epic Tapestry, QNXT, and most homegrown claims environments.

No IT lift

Look-back audit can start with a single claims extract drop. Live monitoring takes 2–4 weeks of stand-up.

HIPAA · SOC 2 in progress

BAA on day one. SOC 2 Type II observation window underway. Google Cloud Healthcare partner.

Built for the operators
who live inside delegated risk.

CFO & Finance

Recover dollars that have already left the door. Forecast risk-pool performance with claim-level evidence.

VP Claims & Operations

Stop relying on examiner interpretation. Make every adjudication consistent with the contract.

DOFR & Configuration

One source of truth for every contract, every version. No more reconciling PDFs and spreadsheets by hand.

Compliance & Audit

A defensible, auditable trail from contract clause to claim payment. Ready for any review.

The AI engine that
reads your DOFRs
and every claim against them.

Four modules.
One source of truth.

Pull in what you already have.

Translate contracts into rules.

Run every paid claim against the codified contract.

Catch the next leak before it leaves the door.

The product, end to end.

Every variance comes with the
contract clause that proved it.

Every contract your team has,
codified and versioned.

Sits on top of your stack.
Not in it.

Flat-file friendly

Platform agnostic

No IT lift

HIPAA · SOC 2 in progress

Built for the operators
who live inside delegated risk.

See what your last quarter
looks like through ARIA.

The AI engine thatreads your DOFRsand every claim against them.

Four modules.One source of truth.

Pull in what you already have.

Translate contracts into rules.

Run every paid claim against the codified contract.

Catch the next leak before it leaves the door.

The product, end to end.

Every variance comes with thecontract clause that proved it.

Every contract your team has,codified and versioned.

Sits on top of your stack.Not in it.

Flat-file friendly

Platform agnostic

No IT lift

HIPAA · SOC 2 in progress

Built for the operatorswho live inside delegated risk.

See what your last quarterlooks like through ARIA.

The AI engine that
reads your DOFRs
and every claim against them.

Four modules.
One source of truth.

Every variance comes with the
contract clause that proved it.

Every contract your team has,
codified and versioned.

Sits on top of your stack.
Not in it.

Built for the operators
who live inside delegated risk.

See what your last quarter
looks like through ARIA.