Adjudication, settlement and oversight for HMOs.
The HMO portal is Vetra's command centre — the screens your claims, finance, network and compliance teams live in every day.
The HMO dashboard — KPIs, claims received today, settlement run, loss ratio and fraud flags
Screenshot — coming soon
The modules
| Dashboard | KPIs across claims, settlements, loss ratio and fraud. |
|---|---|
| Clients & Enrollees | Corporate clients, plan assignments, dependants, lifecycle. |
| Plans & Benefits | Plan tiers, benefit limits, copays and exclusions. |
| Network (Providers) | Provider directory and your linked providers. |
| Authorizations (PA) | Queue with urgency, SLAs, auth codes and appeals. |
| Claims | Adjudication queue, queries, attachments, decisioning. |
| Piles | Provider + billing-month batches of claims for batch vetting. |
| Finance | Settlement runs, remittances, payment proofs. |
| Capitation | Per-enrollee monthly capitation payouts. |
| Reports | 8 live reports — loss ratio, utilisation, provider performance, claims aging, settlement summary, fraud & anomaly, authorisation, enrollee coverage. |
| Approval Limits | Per-role approval ceilings for claims and settlements. |
| Roles & Users | RBAC with 55+ permissions; scoped staff invites. |
| Settings | Tenant branding, billing, integrations. |
How adjudicators actually work
The claims queue is ranked by AI risk score, SLA urgency, value and payer rules. An adjudicator opens a claim and sees:
- The full encounter — patient, diagnosis, provider, line items.
- Eligibility verdict and plan benefit limits per line.
- AI-flagged anomalies with the rule that triggered them.
- The communication thread (queries) and any attachments.
From there: Approve in full or part, Query the provider (asking for a specific document or clarification), or Reject with a coded reason. Every decision is audit-logged.
Single claim view — line items, eligibility verdict, AI flags and query thread
Screenshot — coming soon
Piles — for batch vetting
A pile groups every claim from one provider in one billing month. The pile view shows progress, AI-flag summary, total value and a "Vet next" button that walks the manager through outstanding claims in priority order.
The Piles workspace — provider + billing-month batches with progress, AI-flag summary and a Vet next CTA
Screenshot — coming soon
Finance & settlements
- Schedule settlement runs (weekly / bi-weekly / monthly).
- Each run groups approved claims into a remittance per provider.
- Upload the payment proof — the provider sees it instantly.
- Resolve provider disputes against remittances with a clear audit trail.
- Capitation is a separate monthly payout per enrollee to designated primary providers.
A settlement run with per-provider remittances and a payment-proof upload
Screenshot — coming soon
Reports
All eight reports run on live data with KPIs, trend, breakdown, filterable table and CSV export.
- Loss ratio
- Claims utilisation
- Provider performance
- Claims aging
- Settlement summary
- Fraud & anomaly
- Authorisation
- Enrollee coverage
Watch a full walkthrough
HMO portal — end-to-end operator walkthrough
Roles, plans, providers, adjudication, settlement and reports in a single tour.
Walkthrough — coming soon
Take this with you
The HMO role guide bundles this content into a single downloadable Markdown for offline review.
Open the HMO guide