The platform
Watch one claim move through Grivara.
Four acts. Seven scenes. Ten specialists. One decision packet. Scroll to see how an ambiguous health claim at Northvale goes from PDF to signed audit trail — in minutes, not weeks.
Scene 1 · FNOL arrives
A claim lands as documents, not data.
9:14 AM. A new claim hits Northvale's intake queue — one EOB, one itemized bill, one referral. No structured fields yet. Everything is prose and PDF.
EOB · Northvale
Patient: REDACTED (member #••••4821) Dx: H66.9 — Otitis media, unspecified Procedures: 70551 MRI brain, without contrast 76536 Ultrasound, soft tissue neck Billed: $4,800.00
Scene 2 · Extraction
Documents become a graph, not a table.
Extraction doesn't just pull fields. It connects every piece of the claim — member, provider, diagnosis, procedures, referring doctor — into a live map of who touched what. The moment the provider's ID lands, the map already shows two prior flagged claims from the same provider. Fraud rings surface the instant they form, not weeks later when a pattern finally becomes obvious.
Provider 1528 is already linked to a prior flagged claim (CL·0007). The ring is visible before the adjuster opens the file.
Scene 3 · Specialists fire
Four specialists. Four findings. Every one cited.
Coverage, Evidence, Fraud, and Compliance run concurrently. Each one cites the policy clause, registry, or guideline it relied on. Your adjusters don't get a verdict — they get a finding with its sources next to it. No guesswork, no black box.
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Scene 4 · Runtime gates
Nothing runs without passing the gates.
Seven approval gates check the specialists' work against Northvale's own rules. Required evidence is present. Medical necessity fails on imaging. The fraud signal lands above the review line. One gate flips.
Scene 5 · HITL routing
Human at the keyboard, not in the loop forever.
Because one gate flipped to review, the claim routes to a medical director. Not auto-denied. Not auto-approved. The specialist sees the full agent trace, the cited policy text, and one-click options: approve, request records, deny with reason, or escalate to SIU.
Medical Director · Inbox
CLM-MED-0010 · MRI + US for otitis media
Elevated fraud · medical necessity fail
Scene 6 · Decision packet
The packet is the product.
Every claim ends with the same record: what each specialist found, the policies and guidelines they cited, the coverage call, the recommended action, and a complete history your team can replay. This is what regulators see. This is what auditors sign.
Decision record · CLM-MED-0010
- Claim
- CLM-MED-0010
- Coverage
- Question — prior auth missing
- Fraud signal
- Elevated
- Flags
- Dx mismatch · Imaging · Upcoding
- Cited
- Policy §4.2 · Clinical guidelines
- Recommended action
- Request more records
- Review required
- Medical director
- Audit
- Replayable · signed
Scene 7 · Action + audit
Closed loop. Signed trail.
Once the medical director approves, the action fires into your core system: request additional records, hold billing, route to medical review. Every step — what each specialist did, what the gates decided, who approved — lands in a signed, replayable record.
{ "action": "request_documentation", "required": ["medical_records", "referral"], "hold_billing": true, "signed_by": "md.carter", "config_version": "v12"}
EOB · Northvale
Patient: REDACTED (member #••••4821) Dx: H66.9 — Otitis media, unspecified Procedures: 70551 MRI brain, without contrast 76536 Ultrasound, soft tissue neck Billed: $4,800.00
A real pilot case from the Northvale synthetic batch. Ground truth: pend for medical review, fraud signal present, 10-day cycle target.
The roster
Ten specialists, one decision packet.
No generalist model. Each agent owns a narrow job, produces a structured output, and hands off to the next.
01
Intake Router
Triages line of business, acuity, and priority.
02
Extraction Agent
Turns documents into structured, cited facts.
03
Coverage Analyst
Applies the active policy version, cites clauses.
04
Evidence Collector
Pulls provider NPI, weather, history, CRM.
05
Fraud Signal Analyst
Catches organized fraud rings, not just lone red flags.
06
Compliance Agent
HIPAA, state rules, timing, appeal rights.
07
Customer Comms Agent
Plain-language notices, EOBs, escalations.
08
Reserve Analyst
Sets reserves against authority thresholds.
09
Orchestrator
Synthesizes specialists into one recommendation.
10
Action Executor
Sends decisions to your core system and captures the receipts.
Surfaces
Four ways the product meets your team.
One backend. Four front doors, each tuned to a role.
Claims Cockpit
Your adjuster's single screen. Timeline, citations, evidence, approve — all in one place.
Specialist Inbox
Every claim that needs a human looks the same: reason at the top, one-click actions, no hunting for context.
Policy Console
Upload, version, activate, rollback. Chat against any version with citations.
Audit Trail
Signed, replayable record of every decision, override, and approval.
Your data, your rules
Your book stays yours. Every decision replayable.
Your claim data is isolated from day one. Pick the AI vendors your security team has already approved. Set your own thresholds. Bring your own data. And replay any decision an auditor asks about.
Your book stays yours
Your claim data lives in its own workspace — not a shared pool. No other carrier, TPA, or health plan on Grivara can see a byte of it. Isolation is built in, not layered on with permissions.
Use the AI you trust
Run Grivara on OpenAI, Anthropic, or a private deployment — whichever your security team has already cleared. Swap vendors whenever you want. Your specialists don't need to be retrained.
Replay any decision
Every decision is sealed with the exact rules and data it used. Pull up a claim from last quarter, run it again with today's policy, and see what changed. Show an auditor the chain of reasoning from six months ago.
Your data, protected
Claim files stay encrypted. Patient and personal information is removed before any AI model sees a word of it. Your audit log can be read — but never edited.
Where it fits
Grivara vs. the alternatives.
| Capability | Legacy core | BPO | Generic copilot | Grivara |
|---|---|---|---|---|
| End-to-end claim pipeline | ||||
| Cited decisions, no black box | ||||
| Pre-flight + real-time approval gates | ||||
| Human approval on deny / SIU / over-authority | ||||
| Signed, replayable audit trail | ||||
| Specialists tuned per line of business | ||||
| Actions that land in your core system | ||||
| Minutes to decision, not weeks |
Walkthrough
See your next claim move in real time.
Thirty minutes. We bring a live pipeline wired to a synthetic tenant like Northvale. You bring one claim — or let us run CLM-MED-0010 again.
- Live decision record
- Approval rules in action
- Human review preview
- Replay the audit trail
No install. No PHI in the demo. NDA on request.