For payers
Medical trend runs high. Admin cost has to fall.
An AI operating partner that measures where hours go in one claims, enrollment or UM team, then builds and runs the replacement.
Who it is for
Find your plan type.
- Often first: Pend queues, 834 fallout or UM fax intakeMeasured by: Pend age, touches per claim, turnaround
- Often first: 834 and 820 reconciliation or encounter rejectsMeasured by: Encounter acceptance, reconciliation backlog
- Often first: MMR and state file reconciliationMeasured by: Open mismatches, encounter rejects
- Often first: Pended claims or 834 load errorsMeasured by: Pend age and turnaround by employer group
- Often first: Pharmacy help desk reject calls or PA intakeMeasured by: Handle time, PA decision clocks met
- Often first: Paper claim intake or attachment pendsMeasured by: Claims keyed by hand, pend age
One payer workflow
One prior auth request, and where its clock goes.
- Request lands by fax or portal upload and is read into intakeAI, person checks
- Member eligibility checkedAutomation
- Case keyed into your UM platform from the requestAI, person checks
- Missing clinicals chasedAutomation
- Nurse reviews; a physician signs any denialYour staff decide
- Notice built from the reviewer's rationaleAutomation
Medicare distribution, anonymized
Healthcare servicesCommissions, HR and onboarding rebuilt while the business grew
How we handle regulated data
Design posture, not certification
- BAA
- Where a department handles protected health information, we execute a business associate agreement before Trace is installed or any data is accessed.
- HIPAA
- We execute a Business Associate Agreement before any engagement that touches PHI, and PHI is accessed only inside client-controlled systems by named individuals. Our first healthcare engagement under BAA is in progress.
- Posture
- Ready and aligned describe design posture, not certification. Reliable Group does not currently hold SOC 2 or ISO 27001 certification; our teams operate inside client-certified environments under client controls.
- Notice
- We deploy Trace only after your organization has given team members the written notice required in your state; we provide the notice template.
Questions health plans ask
We measure where the hours go in one claims, enrollment or prior auth intake team, by queue and pend code, then build, run and manage the rebuilt work inside your systems: rules-based automation first, AI where documents need reading, your people for judgment.
A fixed fee, agreed before we start, for a six to eight week discovery of one department. It ends in a workflow map and a fixed-price proposal for the first build. The build is priced separately, with no obligation to continue afterwards.
We start with one team and work inside the core admin, UM platform, portals and file feeds you already run, whether Facets, QNXT, HealthRules Payer, Epic Tapestry, a PBM claims platform or a homegrown one. We do not replace your system of record.
Your client-specific workflows, data and documentation are yours. Trace is Reliable Group software, licensed under the engagement; third-party tools keep their own license terms. When the work needs a team, it is managed by us, in your entity or ours.
No. UM determinations, medical necessity, peer-to-peer reviews, care management and risk adjustment coding stay with your clinicians and certified coders. We work the administrative queue around them: re-keying, fax and phone follow-up, status checks and exceptions.
Where a department handles protected health information, we execute a business associate agreement before Trace is installed or any data is accessed. Access from India happens only where your state Medicaid and CMS contracts allow it, by named individuals inside client-controlled systems.
Next step
Stop guessing how your operation works.
Start with a fixed-fee discovery: one department, six to eight weeks, a workflow map and a fixed-price proposal for the first build.