SmartClaimsHub turns a plan document into structured coverage, routes it for approval, and puts it to work deciding claims.
Every field traces back to the sentence it came from.
Being read correctly, being approved by people outside your walls, and being enforced without drift.
Upload an SPD, amendment, policy or formulary. Coverage comes out as plans, tiers, benefits and rules.
Extraction queue
Nothing gets built on a bad read.
Brokers, consultants, HR leads and counsel are people you can't give logins to. Send them the document anyway.
Reviewer comment, as it lands internally
"Out-of-network coinsurance should be 50% after the out-of-network deductible."
J. Whitfield · attached to MRI / MRA Outpatient · Aug 2, 11:47
Cost share is built as an ordered sequence. The member wording is generated from it.
Cost-share sequence · MRI Outpatient, in-network
Generated member wording
"20% coinsurance after the annual deductible, capped at $500 per scan."
Every employer group isolated, with its own database.
Changed, added, removed — and renames reported as renames.
One written exclusion governs many plans, tiers or benefits.
A retry never duplicates a record downstream.
Author and approvers, on the record, per document.
Clone into next plan year; coverage keeps its identity.
Permissions drive what each user can see and do.
Live status, no refresh, no chasing by email.
No source document? Create the plan structure by hand.
The document becomes a hierarchy every downstream system can read.
The four rule families live at both levels. A document rule links down; a plan rule overrides locally.
Upload. The engine classifies and extracts, with a confidence score.
Reviewers open a personal link, comment on rows, approve or ask for changes.
Approved coverage goes to the claims system. Retries can't duplicate.
Claims run against it. Each decision names its provision.
Change requests loop back to step 2, attached to the exact benefit
What an outside consultant sees. No account. No password. No IT ticket.
Jordan, the 2026 plan document is in your approval queue. This link is personal to you and expires in 14 days. No account needed.
Send the same document to legal, the sponsor and your actuary at once. Each gets their own link, code and audit trail.
We emailed a 6-digit code to
j.whitfield@benefitsadvisors.com
For this demo the code is 482017, type it, or
Comment on any row. Notes collect on the right and submit as one batch.
| Service / Benefit | In-Network | Out-of-Network | Comment |
|---|
Internally, each comment reappears as a callout on that exact row, timestamped and attributed.
Six surfaces, from repository to sign-off to live adjudication.
| Document | Client | Type | Version | Status |
|---|---|---|---|---|
| Acme Manufacturing, 2026 SPD Provisions extracted and reviewed | Acme Manufacturing | SPD | v3 | Published |
| Acme Manufacturing, 2027 SPD Rolled forward from v3 | Acme Manufacturing | SPD | v4 | Draft |
| Northwind, SMM Q3 amendment Tracked against base SPD | Northwind Logistics | SMM | v2 | In approval |
| Harbor Health, medical policy set 142 clinical guidelines, code linked | Harbor Health Trust | Policy | v1 | Changes asked |
| Vertex Retail, 2026 SPD Extraction confidence below threshold | Vertex Retail | SPD | v1 | Held |
Last row: low extraction confidence, so it's held. Nothing gets built on a bad read.
| Service / Benefit | In-Network | Tier 2 | Out-of-Network | Rules |
|---|---|---|---|---|
| Preventive & Primary Care | ||||
| Annual Preventive Physical | $0covered in full | $0covered in full | 40%after deductible | None |
| Primary Care Office Visit | $25deductible waived | $40deductible waived | 40%after deductible | Limit |
| Diagnostic Imaging | ||||
| MRI / MRA Outpatient | 20%after deductible | 30%after deductible | 50%after deductible | Prior auth |
| CT Scan Outpatient | 20%after deductible | 30%after deductible | 50%after deductible | Prior auth |
| Emergency & Urgent Care | ||||
| Emergency Room Visit | $350waived if admitted | $350waived if admitted | $350paid at in-network rate | Eligibility |
| Urgent Care Visit | $60deductible waived | $75deductible waived | 40%after deductible | None |
The same values reviewers approve and the claims engine reads. One table, every tier.
| Entry | Field | Version 3 | Version 4 | Change |
|---|---|---|---|---|
| Annual Deductible, In-Network | Amount | $1,500 | $1,750 | Changed |
| MRI OutpatientMRI / MRA Outpatient same provision, new name | Name | MRI Outpatient | MRI / MRA Outpatient | Renamed |
| Primary Care Office Visit | In-network cost | $25 | $30 | Changed |
| Virtual Behavioral Health | Benefit | Not present | $0 | Added |
| Prior auth, advanced imaging | Document rule | Not present | Required over $1,000 | Added |
| Routine Foot Care | Exclusion | Excluded unless diabetic | Not present | Removed |
| Emergency Room Visit | Everything | $350 | $350 | Unchanged |
Row two is the point: a rename is reported as a rename, not a delete plus an add to reconcile by eye.
| Approval stage | Assigned to | Status | Timestamp |
|---|---|---|---|
| Internal compliance review | M. Alvarez, compliance | Approved | Jul 28, 09:14 |
| Legal review | Outside counsel | Approved | Jul 30, 16:02 |
| Benefits consultant sign-off | J. Whitfield, Benefits Advisors | Changes requested | Aug 2, 11:47 |
| Plan sponsor e-signature | Acme HR Director | Waiting | Not yet |
Jordan Whitfield, Benefits Advisors, change request
Out-of-network coinsurance should be 50% after the out-of-network deductible, and the document's prior-auth threshold reads $1,000 in section 4.2. This provision implies there is no threshold at all. Please align both before sign-off.
Attached to "MRI / MRA Outpatient" in v3, submitted with 6 other notes, Aug 2, 11:47
Each reviewer tracked separately, each response timestamped. Nothing advances silently.
Member-facing language, written automatically
"20% coinsurance after the annual deductible, capped at $500 per scan; covered in full once the out-of-pocket maximum is met."
The SPD wording and the engine's logic come from the same edit. Drift is impossible.
| Claim | Plan | Decision | Governing provision | AI check |
|---|---|---|---|---|
| CLM-88421 MRI Lumbar Spine | PPO Gold 2026 | Pended | Prior authorization rule | Agrees |
| CLM-88418 Annual Preventive Physical | HDHP Core 2026 | Approved | Preventive covered in full | Agrees |
| CLM-88402 Cosmetic procedure | PPO Gold 2026 | Denied | Cosmetic surgery exclusion | Agrees |
| CLM-88397 ER visit, out-of-network | PPO Gold 2026 | Approved | Emergency care eligibility rule | Disagrees |
| CLM-88384 Physical therapy, 21st visit | HDHP Core 2026 | Denied | 20-visit annual limit | Agrees |
Every decision links to its governing provision. Highlighted row: rules approved, AI disagreed, human deciding.
Pick a claim and a plan. Watch the engine walk eligibility, exclusions, prior auth, limits and cost share.
Both are published 2026 SPDs for Acme Manufacturing. The HDHP applies the deductible before coinsurance.
Rules decide. The model advises. It can agree or raise its hand, never override. So you never have to defend "the AI decided."
Same platform, different pressure.
AI does the reading and the second opinion. The rule engine does the deciding.
Sample figures shown to illustrate the reporting screen. Not performance claims.
Health plan data doesn't get the benefit of the doubt. Neither does an AI decision.
Every request is signed and tied to the browser that issued it (DPoP, RFC 9449). A stolen token alone is useless.
Reviewers hold no account. One link, one person, one document, verified per session by a one-time code.
A separate workspace and a separate database per client organization. Nothing co-mingles.
Approvals, comments, publications and decisions each carry a timestamp and an owner.
Decision Tree Consulting, which builds and hosts SmartClaimsHub, holds an independently audited SOC 2 Type II report covering Security, Availability and Confidentiality.
Encrypted at rest and in transit, role-based minimum-necessary access, and every action written to an audit log.
Version history, timestamped sponsor sign-off and provision-to-decision traceability support the recordkeeping and disclosure practices ERISA and ACA plan administration require.
We'll ingest it live, build the coverage, route it to someone on your team for review, and adjudicate a claim against it.