How Claimloom Works
From packet arrival to flag summary in under 60 seconds.
The pre-adjudication check logic that used to exist only in a senior adjuster's head — systematized into 40+ discrete rules, running before the claim enters a human queue.
Integration options
Two paths into the same check engine. Use whichever fits how claim packets currently arrive at your operation.
REST API
POST the claim packet as JSON to your assigned Claimloom endpoint. Receive the structured check result synchronously within the SLA window.
Email Drop
Forward the claim packet email to your dedicated Claimloom inbox. Attachments are ingested automatically, check results return to your integration address.
// Request
"claim_id": "CLM-2024-09112",
"documents": [
"er_record_2024-10-08.pdf",
"invoice_hartford_med.pdf",
"claim_form_signed.pdf"
]
// Response
"status": "flagged",
"checks": [
{ "id": "DOC_POLICE_REPORT",
"status": "MISSING" },
{ "id": "DATE_INCIDENT_VS_ER",
"status": "MISMATCH",
"detail": "2-day gap" },
{ "id": "INVOICE_TOTAL_MATCH",
"status": "PASS" }
]The 40+ checks, by category.
Four check categories, each targeting a distinct failure mode in claim packet intake. Claims directors reviewing Claimloom typically start here.
- Police report attached (where required by claim type)
- Emergency room or physician record present
- Repair estimate or appraisal attached
- Prescription or pharmacy records where indicated
- Photos/evidence attachments count check
- Death certificate present on life/AD&D claims
- Proof-of-loss form submitted and dated
- Authorization for release of records signed
- Incident date precedes treatment date
- Treatment date precedes invoice date
- Coverage effective date precedes incident date
- Claim submission within policy reporting window
- Invoice dates consistent across multiple providers
- Adjuster assignment date after claim receipt date
- Statute of limitations flag on older dates
- Invoice line items sum to invoice total
- Deductible applied correctly to billed amounts
- Duplicate line-item charge detection
- Billed amounts within reasonable range for procedure codes
- Cross-invoice duplicate charge detection (multi-provider)
- Payment amounts match settlement agreement where present
- Tax and fee line items consistent with jurisdiction
- NPI number format valid (10-digit Luhn check)
- NPI consistent across documents in packet
- State license number format valid for stated jurisdiction
- Provider name matches across invoice and ER record
- Facility DEA number format valid where applicable
- Taxonomy code present and consistent with billed services
What your adjuster sees.
A structured flag summary reaches the adjuster's queue — not a raw data export, but a prioritized list: what's missing, what mismatches, what passed. MISSING items rank above MISMATCHes; PASSed checks are shown but don't lead.
Delivered via webhook push to your claims system or via email to your adjuster assignment queue. Configurable per carrier program or TPA client.