Pending-claim screening
Prepay rules evaluate pending claims against the member's claim history and the current reference data.
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AEGIS ISD Detect
Prepay and postpay detection for healthcare claims.
Detect screens pending claims before payment and scans paid claims after payment with one governed rule library. Alerts go to prepay reviewers and alert analysts, and then into Case Management when a case needs to be opened.
Prepay + postpay
100+ base rules
CMS NCCI & MUE
MS-DRG
Link analysis
One rule library, two payment stages
Catch problems before payment and find them after.
Every rule carries a payment stage: prepay, postpay, or both. Prepay rules check only pending claims. Postpay rules check paid and adjusted claims. Each stage gets the workflow it needs.
Deciding which rules run before payment and which run after? Read our guide: prepay vs postpay FWA detection.
Prepay
Before the claim is paid
Pending claims are screened and get a recommended action of deny, suspend, review, or flag. Reviewers release, suspend, or deny with a recorded reason, and finalized decisions are exported for handoff to your claims system.
Prepay capabilitiesPostpay
After the claim is paid
Paid and adjusted claims are scanned in detection runs and risk-scored. Analysts triage alerts with evidence and convert the ones that need investigation into Case Management leads.
Postpay capabilitiesPrepay
Pre-payment screening with reviewer control.
Detect makes recommendations. Your claims system and reviewers keep the payment decision.
Recommended actions
Each rule recommends deny, suspend, review, or flag for the whole claim or specific lines. The strongest recommendation wins, and a claim that cannot be fully checked is suspended rather than passed.
Claim-at-a-time API
Evaluate a single incoming claim through the Rules API, or opt a model into deadline-prioritized micro-batches with latency budgets.
Prepay review workspace
Needs review, Flagged, Screening exceptions, and Historical queues with assignment and filters. Reviewers release, suspend, or deny at claim or line level with a required reason.
Prepay targeting
Put specific providers, members, or models on prepay review, or set an organization-wide default. Changes to the flag list are audited and versioned.
Export and handoff
Finalized decisions are exported as retained CSV batches and marked handed off with a reference. Escalate any claim to a Case Management lead with the claim and decision attached.
Postpay
Post-payment detection runs and alert triage.
Risk-scored alerts
Postpay rules scan paid and adjusted claims. Every alert carries a 0 to 100 risk score that drives the alert queue, insights, and scorecards.
Flexible detection runs
Runs start when DataBridge loads new claims, on demand, or as a retrospective backfill. Peer cohorts and billing tiers are computed for the point in time of the run.
Dry run, then promote
Estimate the claim volume, run a dry run, review and export the dry-run results, then promote them to alerts or discard them.
Alert queue
Statuses from new to resolved or false positive, assignment, history, saved searches, evidence drill-down, scorecards, and CSV export.
Provider and member profiles
Claim statistics, peer percentile comparisons, linked alerts, and payment-stage flags. Member identifiers are masked, and revealing them is permission-checked and audited.
Handoff to Case Management
Convert an alert to a Case Management lead in one step with the evidence attached. Case outcomes sync back to the alert.
Base rule library
100+ SIU base rules across seven categories.
Two published decision services, base postpay rules and base prepay rules, are installed for every organization. Each rule's parameters, payment stage, prepay action, and risk score can be tuned, and your own rules sit alongside them.
| Category | Examples |
|---|---|
| DRG | Short sepsis stays, length of stay below the geometric mean, single CC/MCC severity driver |
| Utilization | MUE units, frequency limits, critical care time, observation hours |
| High dollar | Lab, drug, nutrition, facility claims, out-of-network without modifier |
| Unbundling | NCCI procedure-to-procedure edits, critical care bundles, E&M without modifier 25 or 57 |
| Duplicates and FWA | Exact duplicates, same service by any provider, lab travel without a collection |
| Coding abuse | Multiple E&M visits on the same day, modifier 25 patterns |
| Upcoding | Ground ambulance mileage |
Rules Studio and reference data
Author, test, and govern every rule.
Visual rule designer
Build rules and decision services visually, and promote them through development, UAT, and production with governance at each step.
Fork and tune base rules
Fork any base rule into an editable rule graph, or adjust its parameters, payment stage, prepay action, and risk score through draft, test, and publish.
One-click test scenarios
Generate positive and negative test scenarios for a rule, test against synthetic claim history, and run simulations and replays before going live.
CMS NCCI and MUE
CMS NCCI procedure-to-procedure and MUE edits for Medicare and Medicaid practitioner, outpatient hospital, and DME services, managed centrally and pinned per organization.
MS-DRG
MS-DRG FY2026 and FY2027 reference data with CC/MCC and principal-diagnosis collections, plus organization reference lists and billing tiers for peer groups.
Explainable alerts
Every alert carries rule provenance, reason codes, and the evidence behind it, so reviewers and investigators can see why a claim was flagged.
Link analysis
See the networks behind the claims.
Link analysis builds provider networks from your claims data and finds relationships that single-claim rules cannot see. It is available as a Detect add-on.
Provider network builds
Build provider relationship networks from the claims tables your administrators choose.
Networks explorer
Explore networks in an interactive graph with search and saved views.
Shared-member concentration
Find provider pairs that bill for an unusually concentrated set of the same members.
Referral concentration
Find provider pairs with concentrated referral patterns, with a data-coverage check so sparse referral data does not produce false alerts.
Coordinated billing
Find provider pairs with coordinated billing patterns across shared members.
Network alerts with trial mode
Each detector runs in trial mode first, so you can review its trial results before they become alerts. Trial results keep their revision history.
Relationships on profiles
Provider and member profiles show their relationships, and Case Management's entity profiles add a Network tab.
Network features in rules
Use relationship features in your own detection models alongside claim-level rules.
Watch lists
Watch providers and members and get in-app and email notifications when new alerts arrive for them.
Built for claims volume
Detection runs execute on Apache Spark over an Apache Iceberg lakehouse, with Trino for analytics. Large runs can be routed to a dedicated compute pool, and alerts stay lean in the operational database.
Works with
One platform, connected products.
Shared identity, permissions, tenant isolation, and audit history across every AEGIS ISD product.
Case Management
Convert alerts and prepay escalations into leads with the evidence attached.
Explore Case ManagementDataBridge
Governed claims, provider, and member data loads that trigger detection runs.
Explore DataBridgeAEGIS AI
Evidence-linked assistance for reviewing alerts and cases.
Explore AIWho it's for
Built for payment integrity and detection teams.
- Prepay and payment integrity teams
- Program integrity analysts
- Special Investigations Units (SIU)
- Fraud strategy and rule authors
- State Medicaid agencies and health plans
See how Detect fits a health plan program: payment integrity software for health plans.
What the demo covers
- Prepay screening and the prepay review workspace
- Postpay detection runs and the alert queue
- The base rule library and rule tuning
- Building and testing a rule in Rules Studio
- Provider and member profiles
- Handing an alert off to Case Management
FAQ
Common questions about AEGIS ISD Detect.
Does Detect deny claims automatically?
No. Detect returns recommendations of deny, suspend, review, or flag. Prepay reviewers make the decision, and the payment action stays with your claims system.
Can one rule run both before and after payment?
Every rule has a payment stage of prepay, postpay, or both. Rules whose inputs exist before payment can be moved to prepay or both without rewriting them, while rules that depend on paid amounts stay postpay.
What rules are included?
100+ base rules across DRG, utilization, high dollar, unbundling, duplicates, coding abuse, and upcoding, backed by CMS NCCI, MUE, and MS-DRG reference data. You can tune them, fork them, and add your own.
How are rule changes tested before they go live?
Generate positive and negative test scenarios, test against synthetic claim history, and use dry runs to see real results before promoting them to alerts.
Can Detect run without Case Management?
Yes. Detect runs standalone for prepay review and alert operations. When Case Management is deployed, alerts and prepay escalations become leads in one step.