AI Solutions for Healthcare

Clinical Scope

Accelerate prior authorizations with AI-assisted reviews and integrity checks

Codoxo Clinical Scope

Clinical Scope accelerates emergent decisions and helps clinical teams and medical directors process authorization requests faster with an AI-assisted solution.

Our AI-assisted claims integrity solution is popular with pre-authorization Clinical Teams and Medical Directors at major healthcare companies and agencies in North America. It includes:

AI analyzes all authorization requests

and correlates them with recent provider and claims data, to give you insights into the recent behavior of the provider, facility, pharmacy and member involved.

Pre-auth analysis flags problematic requests

and gives clinical teams unique insights that inform the best next steps.

AI-based Prior-Auth Scores

can be incorporated into your authorization approval process. Prior Auth Scores flag authorization requests that fail to follow normal clinical care standards. Clinical Scope provides detailed explanations for each Auth Request Risk score.

Gold Carding

Green light low risk authorizations for gold carded providers.

Pause authorization requests

from providers associated with current FWA schemes or from providers flagged by the Codoxo Community.

Accelerate pre-auth reviews

and ensure every referral is to a legitimate physician with an auto-approval rules engine that can be customized and fine-tuned by each client over time.

Authorization Hub

gives clinical teams one place to quickly review all pre-auth request details, and built-in workflow to approve, pend or send medical document requests for further analysis.

Prior auth compliance dashboard and rich reporting

on claims, providers and authorization requests makes it easy for anyone to search, filter and view similar requests for this member – without any help from IT.

Integrated workflows

can send automated requests for more information to providers with a history of problematic claims and also integrate back into your core claims systems.

Reduce professional abrasion

and ensure professionals with high Provider Integrity Scores get fast authorizations for their patients.

AI analyzes
all claim types

Codoxo can ingest and analyze all professional, facility, pharmaceutical, behavioral, dental, and workers comp claims.

AI analyzes
all CODES

Our patented AI technology has the ability to identify issues and opportunities that may arise from complex claims and codes in addition to the standard ones which helps discover a wider range of existing and emerging problems.

Clinical Scope is built on our Forensic AI Platform and a part of the Codoxo Healthcare Integrity Suite

Codoxo_ProductStackDiagram_ClinicalScope

Our AI engine analyzes your claims data, detects practices that intentionally or unintentionally waste money, and builds connections across your data to provide actionable insights.

Codoxo_ProductStackDiagram_ClinicalScope

We invest heavily in our people and our technology to help us push the boundaries of what’s possible.
We have helped achieve savings at world-class payers and healthcare agencies including:

Highmark

6+ million members

State Medicaid Agency

1.5+ million recipients

Southeast Health Plan

3.5+ million members

Pacific Health Plan

700k+ members

Mid-State Health Plan

3.5+ million members

Midwest Plan

2.5+ million members

We invest heavily in our people and our technology to help us push the boundaries of what’s possible.

We have helped achieve savings at world-class payers and healthcare agencies including:

Highmark

6+ million members

State Medicaid Agency

1.5+ million recipients

Southeast Health Plan

3.5+ million members

Pacific Health Plan

700k+ members

Mid-State Health Plan

3.5+ million members

Midwest Plan

2.5+ million members

Ready for a better solution?

Request a demo to learn what we can do for you.

FORENSIC AI PLATFORM

Our Forensic AI Engine analyzes your data, detects problems, and builds connections across your data to provide actionable insights

Insight Scope

For everyone across the health plan

Clinical Scope

For clinical teams

Network Scope

For network teams

Payment Scope

For payment integrity teams

Provider Scope

For network and payment teams

Fraud Scope

For SIU teams

SERVICES

We provide a full range of professional services, from data migration and ongoing customer success through flexible virtual SIU options.

Fraudscope is now Codoxo. LEARN MORE >