Workflow

The end-to-end claims lifecycle.

Every claim on Vetra walks a single, observable state machine — from provider submission through HMO decisioning to settlement.

The state machine

text
SUBMITTED  ─►  RECEIVED  ─►  IN_REVIEW  ─►  APPROVED ─►  SETTLED
                                       └─►  QUERIED ─►  RESUBMITTED ─►  IN_REVIEW
                                       └─►  REJECTED

The claims queue with each claim's current status, AI risk score and SLA timer

Screenshot — coming soon

The claims queue — every state visible at a glance.

States in detail

SUBMITTEDProvider has sent the claim — pending receipt by the HMO's queue. Per-claim billing event fires here.
RECEIVEDHMO has accepted into adjudication. SLA timer starts. This is the per-claim billing trigger to Vetra.
IN_REVIEWAn adjudicator has it open. AI risk score and benefit limits are surfaced.
QUERIEDAdjudicator asked the provider for clarification or extra attachments.
RESUBMITTEDProvider answered the query — back into the queue at higher priority.
APPROVEDApproved in full or part. Eligible to be rolled into a settlement run.
REJECTEDDeclined with a coded reason. Provider may appeal where applicable.
SETTLEDIncluded in a settlement run. Provider sees the remittance and (once uploaded) the payment proof.

What happens at submission

  • Eligibility check against the enrollee's plan and effective dates.
  • Benefit-limit lookup per line item.
  • AI risk scoring (duplicate billing, impossible service dates, upcoding patterns, rapid-fire submissions).
  • Auto-routing into the right queue, including any provider Pile for the billing month.

Queries

A query is a structured back-and-forth: the adjudicator asks for something specific (e.g. "Please attach the operating notes"), the provider replies on the same claim, and the claim is RESUBMITTED. Every query and attachment is part of the audit log.

Queries are not chat

A query has a single open question at a time. That's intentional — it keeps decisioning auditable and prevents drift.

A query thread on a claim with the open question, the requested attachment and the provider's reply

Screenshot — coming soon

A query — single open question, single reply.

Decisions and audit

  • Every approve / query / reject action is recorded against the user and timestamp.
  • Partial approvals record the line-item-level decision.
  • Approval limits enforce ceilings — if a value exceeds your limit, the action requires escalation.
  • Decisions trigger notifications to the provider and the enrollee.

The audit log for a single claim — every action with actor, timestamp and before/after

Screenshot — coming soon

The audit log on a claim.

Watch the lifecycle end-to-end

A claim from submission to settlement

One claim, three roles — provider submits, HMO adjudicates, finance settles.

Walkthrough — coming soon

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