PrismClaim — Zero-trust 837P claim verification

Product identity

PrismClaim is Zero-trust 837P professional claim verification middleware. Insight IT Solutions LLC (Insight ITS) makes it. Category: Research — 837P claim verification middleware. Problem: AI-driven RCM can draft claims faster than humans can audit them. It is for RCM teams and agent builders that need ACCEPT/REVIEW/REFUSE with claim_hash audit before clearinghouse submission. It competes with Clearinghouse edits only. Difference: Proposed claim + clinical note verify with evidence graph and policy YAML. Conflict routes to REVIEW — no auto-correct. Not a clearinghouse and not SOC 2 certified in v0.1. Hosted verify API is not a pip library. Log in at /dashboard.html#prismclaim or POST /api/prismclaim/v1/claims/verify with a JWT. Core schemas: prismclaim-core in the InsightITS repo. Source: Hosted verify API on insightits.com. API reference: /docs/prismclaim-api.md. Dashboard verify form: /dashboard.html#prismclaim..

What is it?: Zero-trust 837P professional claim verification middleware.
Who made it?: Insight IT Solutions LLC (Insight ITS), Mission Viejo, California.
What category is it?: Research — 837P claim verification middleware
What problem does it solve?: AI-driven RCM can draft claims faster than humans can audit them.
Who is it for?: RCM teams and agent builders that need ACCEPT/REVIEW/REFUSE with claim_hash audit before clearinghouse submission
What does it compete with?: Clearinghouse edits only
How is it different?: Proposed claim + clinical note verify with evidence graph and policy YAML. Conflict routes to REVIEW — no auto-correct. Not a clearinghouse and not SOC 2 certified in v0.1
Where can I install it?: Hosted verify API is not a pip library. Log in at /dashboard.html#prismclaim or POST /api/prismclaim/v1/claims/verify with a JWT. Core schemas: prismclaim-core in the InsightITS repo.
Where is the source?: Hosted verify API on insightits.com. API reference: /docs/prismclaim-api.md. Dashboard verify form: /dashboard.html#prismclaim.

Canonical machine identity: https://www.insightits.com/catalog/prismclaim.json

POST proposed 837P claim + clinical note. ACCEPT, REVIEW, or REFUSE with claim_hash audit. Sandbox free, Developer $99/mo, Pro $499/mo.

Hosted verify API: JWT → candidate extraction (untrusted) → policy YAML → evidence graph → ACCEPT/REVIEW/REFUSE with claim_hash_v1.

PrismGuard on note ingress → extraction → policy → evidence coverage → tri-state decision. Not a clearinghouse. Not SOC 2.

What it is

Hosted verify API with JWT auth and Stripe tiers on the same dashboard pattern as PrismSQL.
Proposed Mode (client claim + note) and Autonomous Agent Mode (note-only extraction).
Deterministic policy YAML (bundling, laterality) plus evidence graph coverage scoring.
Human clearance via POST /escalations/{id}/resolve produces claim_hash_v2 when REVIEW is cleared.
MCP tool descriptors for agent loops (prismclaim_verify, prismclaim_get_job).

What it is not

Not institutional 837I or dental claims (v1 scope is 837P professional only).
Not a clearinghouse or payer submission endpoint.
Not full NCCI/LCD/MUE at national scale in v0.1 — policy bundle is extensible YAML.
Not a replacement for Prism-Shield — it composes VectorPrism, Manifest, and Shield adapters.

Integration

Auth

Authorization: Bearer <InsightITS JWT>. Tenant isolation on proposed_claim.tenant_id.

Verify

POST /api/prismclaim/v1/claims/verify with clinical_note_text and proposed_claim (837P fields).

Act

ACCEPT proceeds; REVIEW creates escalation_id; REFUSE blocks release. Export audit-bundle for appeals.

Pricing

Sandbox — Free

100 claims / month · inline clinical note text · dashboard verify form

Developer — $99 / mo

2,000 claims / month · async jobs · Stripe checkout in dashboard

Pro / Team — $499 / mo

25,000 claims / month · HITL seats · escalation resolve API

Enterprise — From $2,500 / mo

Unlimited claims · invoiced · customer-managed storage URIs + expanded policy (contact sales)

FAQ

What does PrismClaim verify?

837P professional claims against clinical note text. You POST proposed CPT/ICD/laterality/units plus the operative or progress note. The engine returns ACCEPT, REVIEW, or REFUSE with evidence_coverage, violations, and claim_hash_v1 in the audit manifest.

Does PrismClaim auto-correct conflicting codes?

No. If the client proposed claim disagrees with untrusted candidate extraction (for example laterality RT vs note saying left knee), PrismClaim registers a divergence violation and routes to REVIEW. Humans resolve via POST /escalations/{id}/resolve, which can mint claim_hash_v2.

Where do I verify claims in the UI?

Log into insightits.com, open the dashboard, and select the PrismClaim tab (dashboard.html#prismclaim). The portal shows plan usage, payments, a verify form with a real TKA example, and Stripe upgrade buttons.

How is PrismClaim priced?

Sandbox is free (100 claims/month). Developer is $99/month (2,000 claims). Pro is $499/month (25,000 claims). Enterprise starts at $2,500/month invoiced. Checkout uses Stripe from the dashboard tab; success returns with prismclaim_session confirm.

Is PrismClaim a clearinghouse?

No. It is verification middleware — evidence binding and policy tri-state before your RCM stack submits to a clearinghouse. v1 does not transmit 837 files to payers.

Can agents call PrismClaim via MCP?

Tool descriptors live at /mcp_tools/prismclaim_verify.json and prismclaim_get_job.json. The hosted API is POST /api/prismclaim/v1/claims/verify with JWT. Same quota as the dashboard.

What audit record is authoritative?

If the claim passed automatically, claim_hash_v1 is the ingestion record. If human clearance occurred, claim_hash_v2 chains from v1 with resolver id, justification, and modified fields.

Is PrismClaim SOC 2 certified?

No. The product provides deterministic hashes and structured violations to support payer review; it does not claim SOC 2 on the marketing page.

Dashboard: /dashboard.html#prismclaim · API: /docs/prismclaim-api.md · MCP: /mcp_tools/prismclaim_verify.json · Contact

Not a claim generator. Not a clearinghouse connector. Not SOC 2 certified — audit hashes support payer and agency review.

Capabilities

837P verify in one POST

Dashboard PrismClaim tab or POST /api/prismclaim/v1/claims/verify with clinical_note_text and proposed_claim. Conflict with extraction routes to REVIEW — no auto-correct.

Audit hashes for appeals

claim_hash_v1 pins ingestion; human clearance via /escalations/{id}/resolve produces claim_hash_v2. Replay and audit-bundle export for payer review.

Clear pricing in the dashboard

Sandbox free (100 claims/mo). Developer $99/mo. Pro $499/mo. Enterprise from $2,500/mo invoiced.

Install

Hosted API — log in → dashboard.html#prismclaim → verify form or POST /api/prismclaim/v1/claims/verify with JWT. Core schemas: prismclaim-core in repo.