Decision Intelligence
Technology OverviewHow It WorksCNLP APIIntelligent Document Processor (IDP)IntelliSync
Use Cases: payors
Prior AuthorizationUM & Clinical ReviewPayment Integrity
Use Cases: Providers
Risk Adjustment & RCMPopulation Health
Who We Serve
Health Plans & PayorsProviders & Health SystemsACOs & Value-Based CarePharma & Life Sciences
Company
About UsNews & RecognitionContactRequest a Demo →
Provider Solutions
Audit-Proof · Risk-Adjusted
ACO / VBC Ready
Integrated RCM Intelligence for Providers & ACOs.
Prior Auth. Coding. Risk Adjustment. One platform.
Revenue cycle failure at the provider level isn't a billing problem, it's a clinical intelligence problem. Denials happen because PA submissions are incomplete. Coding errors happen because unstructured records aren't fully readable. Risk scores are inaccurate because HCC gaps aren't surfaced until it's too late.
Hindsait RCM solves all three with one integrated platform, automating prior authorization, AI-assisted and human-in-the-loop coding, and RAF score optimization across your entire patient population.
Explore the Platform
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Hindsait RCM · Integrated Architecture
Order & Data Ingestion → Clinical Intelligence → Risk Optimization
Block 1: Audit Shield
Automated Prior-Auth
ICD-10 & CPT Extract
Payor Policy AI
API Submission
Secure Audit Vault
Evidence Log
Block 2: Smart Coding
Automated Coding
ICD-10 → HCC Crosswalk
Coding Gap Alerts
Human-in-the-Loop
MEAT Documentation
Validated Output
Block 3: Risk Intel
Population Health Views
RAF Score Calculator
HCC Mapping & Validation
Member Base RAF
Risk Benchmarking
Risk Dashboard
Clinical Notes
→
Audit Trail
→
Evidence Log
→
Submission & Reimbursement ✓
+24%PA ApprovalsFirst-pass rate
↓40%Coding BurdenAI-assisted HCC
100%Audit TrailRADV-ready
+24%First-Pass PA Approvalspayor-aligned submissions improve prior authorization approval rates on first submission
↓40%Coding Burden ReductionAI-assisted coding with human review reduces manual note documentation by up to 40%
RAF↑Risk Score AccuracyHCC crosswalk and gap identification closes coding gaps that leave legitimate risk scores uncaptured
100%Audit Trail CoverageImmutable, timestamped evidence log for every clinical decision, HIPAA compliant and RADV-ready
Platform Architecture
Three integrated building blocks. One audit-proof revenue cycle.
Each building block is a standalone capability, and a more powerful integrated system when deployed together. Clinical data flows from ingestion through coding through risk optimization in one continuous pipeline.
Building Block 01
Audit Proofing Shield
Automated Prior Auth · Secure Evidence Log · API Submission
Automated Prior Authorization
Extract ICD-10 and CPT codes from clinical records, match to payor-specific criteria, and submit via API integration, reducing manual submission effort entirely.
Real-Time Payor Policy Intelligence
Continuous web scraping of payor PA requirements, formulary changes, and coverage policy updates, so submissions always align to current payor expectations.
Confidence Scoring & Routing
Every PA request scored for evidence strength, high-confidence cases submitted automatically, borderline cases routed to clinical reviewers with full AI-surfaced context.
Secure Audit Vault
Every action logged, immutable, timestamped, HIPAA-compliant. The Authentic Evidence Log creates a permanent record of every authorized encounter and clinical decision.
+24% First-Pass Approval Rate
Building Block 02
Intelligent Coding & HCC Crosswalks
Automated + Human-in-the-Loop · ICD-10 to HCC · Validated Output
Automated Coding from Clinical Notes
Clinical NLP reads physician notes and extracts ICD-10 diagnoses, CPT procedures, and HCC-relevant conditions, coded automatically without manual chart review.
ICD-10 to HCC Crosswalk
Automated mapping from clinical diagnoses to Hierarchical Condition Categories, identifying coding gaps and surfacing underdocumented HCC conditions that affect RAF scores.
Human-in-the-Loop Review
Coders review AI-generated suggestions with full source evidence, accepting, modifying, or overriding with every decision traceable to the clinical record that supports it.
Validated & Audit-Proof Coding
Every code validated against source clinical evidence before submission, with full human authorization trail, RADV-ready documentation, and HCC compliance monitoring.
↓40% Coding Burden · HCC Compliance Monitored
Building Block 03
Risk Intelligence & Population Health
RAF Score Calculator · Population Views · Risk Benchmarking
RAF Score Calculator & Member Base RAF
Calculate and optimize Risk Adjustment Factor scores across your entire member/patient population, with validated risk scores, HCC mapping, and benchmark comparison.
Population Health Views
SDOH-aware population segmentation, chronic disease cohort analysis, HEDIS and Stars gap identification, all surfaced from clinical record extraction across your full population.
HCC Compliance Monitoring & Validation
Continuous monitoring of HCC coding accuracy, surfacing undercoded conditions, overcoding risks, and documentation gaps before CMS audit or RADV selection.
Risk Benchmarking & ACO Dashboard
Compare total RAF versus benchmark, track ACO and MSSP performance, and monitor shared savings risk, with real time dashboard visibility across your full practice or health system.
RAF Optimized · ACO Performance Tracked
Provider Prior Authorization
Stop denials before they leave your EHR.
PA denials are not a billing department problem, they are a documentation and intelligence problem. Hindsait RCM surfaces every criteria gap, every missing lab value, and every payor policy (monitored continuously by IntelliSync) change before your team submits a single request.
DENIED
15–20% YoY increase in PA denials across providers. Most are preventable, missing documentation that AI can detect before submission.
Hindsait: Documentation gaps flagged pre-submit
DELAYED
PA processing delays disrupt care delivery, consume clinical staff time, and slow revenue cycles, especially for high-cost specialty procedures.
Hindsait: API submission + confidence routing
Step 01
Clinical Record Ingestion & Extraction
Hindsait reads the full clinical record, EMR notes, labs, prior treatment history, and extracts ICD-10 diagnoses, CPT procedures, and the clinical evidence needed for the PA request.
96% Clinical NLP Accuracy
Step 02
Payor Policy Intelligence & Criteria Matching
Real-time payor policy intelligence matches the extracted clinical evidence against each payor's current PA requirements, flagging gaps and documentation deficiencies before submission.
Continuous Policy Monitoring · 100s of payors
Step 03
Confidence Scoring & Intelligent Routing
Every PA request receives a confidence score, high-confidence, criteria-complete requests route to automated API submission. Borderline cases are flagged for human clinical review with full evidence context.
Human-in-the-Loop for Complex Cases
Step 04
API Submission & Audit Trail
Approved PA requests are submitted automatically via API integration. Every action, extraction, scoring, review, submission, is logged to the Secure Audit Vault for appeals support and compliance documentation.
Immutable Log · Appeals-Ready · CMS-0057-F
PA Request - AI AnalysisCriteria Met ✓
Patient[Redacted] · Inpatient
Primary Dx (ICD-10)J18.9, CAP
Procedure (CPT)99232, Subsequent Hosp.
payorBlue Cross [Policy v4.2]
O2 Sat (criterion)89% ✓ (<92% met)
Prior TreatmentAmox 500mg ✓ (doc.)
WBC14.2 ✓ (elevated)
Documentation GapNone detected
Confidence Score96%
Routing to automated submission
All 3 MCG criteria satisfied · API submission queued
Intelligent Coding Platform
Automated coding + human judgment. Validated. Audit-proof.
The Hindsait coding platform is not a choose-one: automated or human. It's both, working in parallel. AI extracts and codes. Humans verify with source evidence. Every code is validated before it leaves the system. Every decision is traceable back to the clinical record that authorized it.
Automated AI Coding
Analyze Clinical Notes
Clinical NLP reads physician notes, discharge summaries, and operative reports, extracting diagnoses, procedures, and HCC-relevant conditions at full document fidelity.
ICD-10 to HCC Crosswalk
Every ICD-10 code automatically mapped to its corresponding HCC category, identifying gaps between what was coded and what the clinical record actually supports for RAF purposes.
Identify Coding Gaps
AI surfaces HCC conditions documented in clinical notes but not yet coded, chronic diagnoses that support risk adjustment but are missing from the current claim submission.
HCC Crosswalk, Live Mapping
E11.9
→
HCC 19
Type 2 Diabetes, major chronic condition
I50.9
→
HCC 85
Congestive Heart Failure, high RAF weight
N18.3
→
HCC 137
CKD Stage 3, comorbidity capture
GAP ⚠
→
HCC 18
Diabetes w/ complication, undercoded
HUMAN REVIEW
Human-in-the-Loop Validation
Human-in-the-Loop Review
Coders review AI-generated code suggestions alongside the supporting clinical evidence, accepting, modifying, or adding codes with every decision linked to source documentation.
Verify Source Evidence
One-click navigation to the exact page, section, and sentence in the clinical record that supports each code, eliminating chart-hunting and reducing reviewer time by up to 70%.
Authorized Encounter Confirmation
Every code receives human authorization, creating a legally defensible, RADV-ready evidence trail that links each diagnosis to the clinician, the encounter, and the supporting documentation.
Validated & Audit-Proof Output
Every code validated, every decision documented, every action timestamped, RADV-ready, SOC2 + HITRUST audited, and defensible.
ImmutableTimestampedHIPAA CompliantRADV-ReadySOC2 + HITRUST audited
RAF & Risk Intelligence
Population risk optimization for ACOs & value-based care.
For Accountable Care Organizations, RAF score accuracy isn't a compliance checkbox, it's a shared savings calculation. Inaccurate risk scores mean inaccurate benchmarks. Inaccurate benchmarks mean lost revenue and misdirected care resources. Hindsait's Risk Intelligence platform closes both gaps.
RAF Score Calculator
Calculate individual and population-level RAF scores from clinical and claims data, with member-base RAF tracking, year-over-year trend analysis, and benchmark comparison against CMS and peer cohorts.
HCC Mapping & Gap Identification
Automated HCC mapping from clinical records identifies conditions that qualify for risk adjustment but haven't been coded, surfacing legitimate revenue opportunities while maintaining audit integrity.
Population Health Views & SDOH Analysis
Identify high-risk patient cohorts, chronic disease populations, and social determinant risk factors, so targeted care management interventions that improve outcomes and reduce total cost of care.
Risk Adjustment Benchmarking
Compare total RAF versus CMS benchmark and peer ACO performance, tracking shared savings risk, identifying performance gaps, and modeling the financial impact of improved coding capture.
Risk Dashboard, ACO PopulationLive
1.42Member Base RAF, Current Period
CMS Benchmark RAF1.38
RAF versus Benchmark+0.04 ↑
Total Members Scored12,847
HCC Gaps Identified284
HCC Gaps Closed (MTD)196 ✓
Est. Shared Savings RiskProtected ↑
RADV Audit StatusCompliant ✓
HCC Gap Closure Rate (MTD)69%
RAF versus Benchmark+2.9%
MEAT-Aligned Intelligence
Every HCC code, fully justified.
Hindsait surfaces M.E.A.T.-compliant evidence from clinical records automatically, so every HCC code you submit is linked to the documentation that defends it.
RADV-defensible from day one
Evidence Extraction
AI scans every chart for MEAT-qualifying language (vital signs, assessments, prescriptions, procedures), flagged and cited in seconds.
HCC-to-Document Linking
Every risk code is traced to its source record. No unsupported codes, no guesswork. Full evidence lineage for every chronic condition.
Coding Validation
Flags incomplete or unsupported codes before submission, reducing audit exposure and costly post-payment recoupment.
AI-Assisted Chart Review
Coders work faster with AI pre-surfacing the relevant documentation. Fewer missed HCCs, faster throughput, higher confidence on every encounter.
Permanent Evidence Log
Every action. Every decision. Immutable, timestamped, audit-ready.
Clinical Notes
Original clinical documentation, physician notes, labs, discharge summaries, stored as source evidence for every coding and PA decision.
Source of Truth
Audit Trail
Every action timestamped, extraction, scoring, human review, authorization, submission. A complete chain of custody for every clinical decision.
Chain of Custody
Permanent Evidence Log
Immutable record of every authorized encounter, HIPAA compliant, RADV-defensible, and timestamped so every HCC code has an unbroken evidence chain.
Immutable · HIPAA
Submission & Reimbursement
Validated claims submitted with complete coding, audit trail, and evidence log, maximizing clean claim rates and minimizing post-payment audit exposure.
Clean Claims · RADV-Ready
Who We Serve
Built for every provider organization facing revenue pressure.
From independent physician groups to large health systems and ACOs, Hindsait RCM addresses the prior authorization, coding, and risk adjustment challenges that directly affect financial performance.
Health Systems & Hospitals
Large Health Systems
Scale prior auth automation, coding intelligence, and HCC compliance monitoring across thousands of encounters per day, without adding headcount.
- PA automation across all service lines
- Enterprise coding platform with human review
- Population-level HCC compliance monitoring
- Integrated audit vault for all encounters
Explore Health System Solutions →
Physician Groups & Practices
Medical Groups & Practices
Reduce PA denial rates, cut documentation burden, and improve coding accuracy, giving physicians time back for patient care instead of administrative overhead.
- EHR-integrated PA intelligence
- Specialty-specific coding templates
- Denial prevention and appeals support
- Coding accuracy and HCC gap reports
Explore Medical Group Solutions →
ACOs & Value-Based Care
ACOs & MSSP Participants
Optimize RAF scores, close HCC coding gaps, monitor population health, and protect shared savings, with a complete risk intelligence platform built for value-based contracts.
- RAF score calculator and member base tracking
- HCC gap identification and closure workflow
- Total RAF versus benchmark dashboards
- RADV-ready audit trail and documentation
- MSSP and VBC performance analytics
Explore ACO Solutions →
Get the Full Brief
Download the Hindsait RCM Product Brief & Case Study
Complete capability breakdown across prior authorization, coding platform, and RAF intelligence, plus implementation approach and measured outcomes from real provider deployments.
RCM Product Brief
Complete the form to unlock the full PDF
Download the RCM Product Brief
Platform architecture, capability breakdown, ACO RAF optimization framework, and implementation approach. Download begins immediately on submission.
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Ready to stop leaving revenue on the table?
Prior auth denials, coding gaps, and inaccurate risk scores cost provider organizations millions annually. See how Hindsait RCM closes all three, in one integrated, audit-proof platform.
Request a DemoDownload Brief
This Is What Healthcare AI Should Look Like.
Production-deployed with WPS Health. Audit-ready by design. Proven to reduce prior authorization review time by 53%. Hindsait turns clinical records into decision-ready intelligence for prior authorization, clinical review, and payment integrity.
Gartner® recognized, built on 12 years of healthcare-specific clinical NLP, and shaped by 100M+ medical records processed across real clinical workflows.
Request a Demo →See How It Works
53%Prior Auth (PA) EfficiencyDocumented across real PA deployments
100M+Medical Records ProcessedSince 2013, across real clinical workflows
12 yrsHealthcare-Specific AI R&DCNLP trained on clinical data since 2013
3×Faster PA DecisionsTurnaround time across deployed health plans
6–8 wksWeeks to Live DeploymentBuilt to complement, not replace existing systems
PALIVE
Live in ProductionProduction-deployed prior authorization (PA) workflows with audit-ready clinical oversight
Gartner®
2026 Representative VendorGartner Market Guide for Intelligent Prior Authorization, inaugural edition
HITRUST CSFCertified InfrastructureHIPAA + SOC 2 · Enterprise-grade PHI protection at every layer
WPS Health SolutionsLive Production ClientMedicare Administrative Contractor · Jurisdictions 5 & 8
Florida BlueStrategic InvestorGuideWell · One of the largest Blues Plans in the country
Why Hindsait Is Different
Clinical AI that has earned its place in production.
Production deployment in prior authorization requires evidence, controls, and auditability—not marketing claims. Automated evidence matching for clinically clear cases.
With Florida Blue among our strategic backers and twelve years of healthcare-specific CNLP training, Hindsait brings accumulated clinical intelligence built through years of real clinical data, deployment, and refinement.
01
Proven at production scale
100M+ records processed. Live in production at WPS Health, a Medicare Administrative Contractor, processing real PA workflows. Already operating in live authorization workflows.
02
Human-in-the-loop where it matters
Automated evidence matching for clinically clear cases. Clinician review for complex determinations. Live in 6–8 weeks, built to complement, not replace your existing UM, PA, EHR, or claims systems.
03
53% PA efficiency. Verified.
A documented outcome across real deployments, not a modeled projection. Measured across prior authorization and clinical audit workflows, the Hindsait platform delivered 30% time savings.
04
Flexible Deployment. Your Environment, Your Terms.
Deploy on-premises or on cloud — GCP, AWS, or Azure — based on your data governance and security requirements. Same platform, same clinical intelligence, same audit trail. No vendor lock-in. No forced migration.
Production Deployment · Prior Authorization
53%
Efficiency improvement across prior authorization and clinical review workflows
Live in production at WPS Health, a Medicare Administrative Contractor for Jurisdictions 5 & 8. Automated evidence matching where clinical criteria are conclusively met. Clinicians in the loop for complex determinations.
"
Having the Hindsait team deeply integrated with our operational SME's, we were not only able to cut our medical review time by over 50%, we also developed new and novel additional uses and custom capabilities with the Hindsait platform to add greater value to our organization, staff, and customers.
BJ
Brian Janssen
Chief Information Officer, WPS Health Solutions
Download the White Paper →
How Hindsait Works
Clinical intelligence, built in layers.
Every Hindsait decision starts with the same foundation, structured clinical intelligence extracted from the documents you already have. One base layer. Every use case above it.
Use Case Layer, Powered by IDP Clinical Intelligence
Prior Authorization
PA decision support. Criteria-matched. Audit-ready. Human-in-the-loop for complex cases.
Production Deployed3× Faster
UM & Clinical Review
MCG, InterQual, LCD/NCD criteria applied consistently across every concurrent and retrospective review.
Guideline-Aligned30% Time Savings
Payment Integrity
Claims anomaly detection, post-payment clinical review, FWA pattern analysis across your full population.
FWA DetectionPopulation Scale
Risk Adjustment & HCC
HCC coding gap identification, RAF score optimization, and RADV-ready audit trail for ACOs and health plans.
RAF OptimizedRADV-Ready
Revenue Cycle & Coding
Automated ICD-10 to HCC crosswalk, AI-assisted coding with human review, and provider prior authorization.
HCC CrosswalkAudit-Proof
Population Health & More
HEDIS, Stars, SDOH analytics, quality oversight, ACO performance, pharma market access, and RWE.
HEDIS / StarsQuality & Pharma
Structured clinical intelligence feeds every use case above
Foundation Layer
Hindsait IDP
Intelligent Document Processor
One foundation layer, every use case above it. IntelliSync, our automated policy intellgence layer, continuously monitors CMS, payor policies, and clinical guidelines, so every decision the pipeline produces is always aligned to current criteria, without manual updates.
Explore IDP →
Ingest
Any source
any format
Clinical NLP
Context-aware
understanding
Extract & Summarize
Key facts
GenAI summary
Score & Route
Evidence strength
smart routing
Deliver
Real-time API
audit trail
95%
Extraction
Accuracy
<30s
Per
Document
50+
Clinical
Entity Types
Who We Serve
Built for every side of the clinical decision
One platform. Three distinct solution sets, each designed for the workflows, pain points, and buyers that define that segment of healthcare.
Payor Solutions
Health Plans & Payors
Automate PA, UM, clinical audit, and payment integrity while meeting CMS-0057-F mandates and HEDIS benchmarks, without adding headcount.
- CMS-0057-F compliant PA automation
- MCG, InterQual, LCD/NCD decision trees
- Payment integrity & FWA detection
- HEDIS & Stars gap analytics
Explore Payor Solutions →
Pharma Solutions
Pharma & Life Sciences
Accelerate specialty drug access, decode payor policies , and extract real-world clinical evidence to power market access strategy.
- Specialty drug PA automation
- payor policy monitoring, 100s of plans
- Real-world evidence extraction
- HEOR & outcomes analytics
Explore Pharma Solutions →
Provider Solutions
Providers & Health Systems
Reduce claim denials, cut documentation burden by 40%, and optimize ACO and value-based care performance from one clinical intelligence layer.
- AI documentation, 40% burden reduction
- Denial risk scoring pre-submission
- MIPS, Stars, HEDIS gap analytics
- Predictive readmission alerts
Explore Provider Solutions →
Results & Recognition
Trusted by healthcare's most demanding organizations
Magellan Health](https://www.magellanhealth.com/) WPS Health Solutions](https://www.wpshealth.com/) NY Blood Center](https://www.nybc.org/) GuideWell Innovation](https://guidewellinnovation.com/) Hackensack UMC](https://hackensackmeridianhealth.org/en/locations/hackensack-university-medical-center)
"
Hindsait's technology and creative approach have opened new doors in how we use data to manage our business.
Tina Blasi
CEO, NIA / Magellan
"
Hindsait’s proven AI technology and differentiated platform, coupled with its seasoned executive team, set it apart.
Ateet Adhikari
Vice President, Healthbox
"
We worked with Hindsait to fine-tune predictive analytics that would enhance our efficiency without compromising quality.
Laurel Douty
COO, Magellan Healthcare
"
Hindsait's ability to identify meaningful clinical insights creates a better pathway for care delivery across our entire network.
Renee Finley
Head of Innovation, GuideWell
"
Having the Hindsait team deeply integrated with our operational SME's, we were not only able to cut our medical review time by over 50%, we also developed new and novel additional uses and custom capabilities with the Hindsait platform to add greater value to our organization, staff, and customers.
Brian Janssen
Chief Information Officer, WPS Health Solutions
Gartner 2026 Market Guide](https://www.gartner.com/en/documents/7430962) Forbes Healthcare AI Recognition](https://www.forbes.com/councils/forbesbusinesscouncil/2023/11/28/how-ai-is-transforming-healthcare-risk-adjustment/) Gartner Cool Vendor 2017](http://www.prnewswire.com/news-releases/hindsait-inc-named-a-cool-vendor-in-ai-in-healthcare-by-gartner-300465248.html) HITRUST CSF Certified](https://www.newswire.com/news/hindsait-achieves-hitrust-csf-certification-to-manage-risk-improve-21141491) Frost & Sullivan Best Practices Award](http://www.prnewswire.com/news-releases/frost--sullivan-applauds-hindsait-for-pioneering-healthcare-centric-artificial-intelligence-systems-300280393.html)
Proven Outcomes
Efficiency without compromising quality
Every metric to the right comes from a real Hindsait client deployment, not modeled projections. Healthcare Decision Intelligence delivers measurable ROI within the first quarter of deployment.
Built for the buyer who counts cost per review. Hindsait clients report measurable FTE reallocation, faster turnaround, and reduced rework, translating directly to lower administrative cost per clinical decision.
3×
Faster PA Processing
Turnaround time across deployed health plans
+30%
Medical Review Efficiency
WPS Health Solutions deployment
35%
Unnecessary Cost Reduction
Evidence-based AI applied to utilization review
53%
Prior Auth (PA) Efficiency
Documented across real PA deployments
+24%
First-Pass PA Approval Rate
payor-aligned submissions, first time
98%
Decision Consistency
Uniform determinations across every reviewer
News & Recognition