AI in the claims room.
Toda AI turns multi-day claims backlogs into 24-hour decisions — with fraud detection, ICD-10/11 coding, and full audit trails built in.
Health insurers are
drowning in manual work
Across Africa and emerging markets globally, the claims function remains stubbornly manual — slow, expensive, and error-prone.
The Toda AI
adjudication engine
Real-time adjudication
Process claims as they arrive — up to 1,000 claims every 10 minutes with anomaly detection running simultaneously on every submission.
Advanced fraud detection
Longitudinal pattern recognition identifies fraudulent claims with 30–50% fraud reduction, protecting insurer revenues at global scale.
OCR document reading
Automated extraction from scanned and handwritten claim documents. Eliminate manual data entry from paper-based submissions entirely.
ICD-10 / ICD-11 standardization
Every claim validated and mapped to global coding standards — enabling compliance with international health insurance regulations and cross-border reporting.
System integration
Full sync with existing insurer platforms and hospital information systems. No rip-and-replace required — Toda AI layers on top of current infrastructure.
Transparent audit trail
Every adjudication decision is traceable and justified. Build provider trust and satisfy regulatory requirements with complete transparency.
The adjudication workflow
Claim submission & OCR extraction
Claims arrive via API, upload, or direct integration. OCR automatically extracts structured data from paper-based or scanned submissions, eliminating manual entry.
AI pre-screening & fraud detection
Each claim is scored against longitudinal fraud patterns, provider benchmarks, and policy rules. Suspicious claims are flagged for human review before proceeding.
ICD-10/11 mapping & policy validation
Diagnoses are mapped to global coding standards. The system validates benefit entitlements, coverage limits, and pre-authorization requirements automatically.
Adjudication decision
Clean claims are approved, queried, or rejected with full justification codes — all within the defined processing window. Human adjudicators review only flagged edge cases.
Payment processing & provider notification
Approved claims feed into the payment workflow. Providers receive real-time status updates with itemized adjudication decisions.
Choose your
adjudication scale
All plans include core adjudication, OCR, and system integration.
- ✓Pre-configured industry rules
- ✓Standard sensitivity
- ✓OCR auto-reading
- —Editable rule scope
- —Longitudinal fraud detection
- ✓Editable scope, global application
- ✓Adjustable sensitivity
- ✓OCR auto-reading
- ✓Multi-batch simultaneous
- ✓Advanced fraud detection
- ✓Fully editable across all facilities
- ✓Adaptive AI-tuned sensitivity
- ✓Longitudinal fraud patterns
- ✓Per-facility AI calibration
- ✓Dedicated account manager
Turn backlogs into
24-hour decisions.
See Toda AI process your claims in a live demonstration.