ClaimInformatics
- Company typePrivate
- Founded2017
- HeadquartersBloomfield, United States
- Headcount11–50
- GTM typeB2B
- OfferingSoftware
ClaimInformatics firmographics
Firmographics- Name
- ClaimInformatics
- Legal name
- Claiminformatics, Inc.
- Website
- https://claiminformatics.com
- Company type
- Private
- Founded year
- 2017
- Operating status
- Operating
- Headcount range
- 11–50 employees
- Ownership category
- akta.pro rank
Where ClaimInformatics is headquartered
LocationHeadquarters
- HQ city
- Bloomfield
- HQ country
- United States
- HQ region
- North America
Offices1 record
Markets served
ClaimInformatics business model
Business model- GTM type
- B2B
- Offering type
- Software
- Cost components
- Personnel, Technology or R&D, Operations, Marketing or Sales, Infrastructure
Revenue model
- Recovery Revenue Sharing: Transparent recovery model where clients share 50% of identified overpayment recoveries with full reconciliation and provider notifications. Identifies improper payments from past 1-3 years and recovers funds with zero cost to clients.
- Ongoing Monitoring Services: Monthly claims analysis and continuous oversight services providing fiduciary protection documentation. Provides regular touchpoints and monthly reviews backed by analytics.
Pricing tiers
| Model | Billing | Price |
|---|---|---|
| Outcome Based/ Performance | Multi-year contract | Recovery-based pricing with 50/50 split |
| Subscription | Monthly | Subscription for ongoing monitoring |
Go-to-market motion2 records
Distribution channels3 records
Marketing channels6 records
ClaimInformatics product offering
Product offeringCore offering
ClaimInformatics develops a HIPAA-compliant, SOC 2 Type II certified payment integrity and fiduciary compliance platform that discovers and recovers improper payments on behalf of self-funded and captive health plan fiduciaries, employers, TPAs, and benefits brokers. The platform combines its proprietary FOCUS™ framework with a 850+ rule ClaimIntelligence™ Edit Suite to deliver pre-pay edit validation, ongoing monthly claims monitoring, and a 50/50 transparent recovery model. Data is exchanged via secure SFTP using EDI 834, 835, 837, CSV, and pipe-delimited file formats.
Product overview
ClaimInformatics is a payment integrity and fiduciary compliance platform for self-funded and captive health plans, delivering its services primarily through the proprietary FOCUS™ (Fiduciary Oversight, Compliance & Utilization Safeguard) framework and the ClaimIntelligence™ Edit Suite. The platform combines pre-pay editing, post-pay monitoring, and ongoing claims analysis to identify improper payments, ensure ERISA and CAA compliance, and protect plan assets. Key modules include the Pre-Pay Solution (integrated into TPA claims workflows to prevent errors before payment), the CLEAR™ solution (for ASO agreement, SPD, and PBM contract reviews), and a Transparent Recovery Model (sharing 50% of identified recoveries with full reconciliation). The company also offers broker enablement services and ongoing monthly monitoring with 100% claims analysis. Data exchange supports EDI 834, 835, 837, CSV, and pipe-delimited formats via secure SFTP.
Differentiator
Problem solved
Functional benefit
Brands
- FOCUS™ (Fiduciary Oversight, Compliance & Utilization Safeguard): Proprietary framework for fiduciary protection delivering compliance, transparency, and financial integrity for self-funded and captive health plans and TPAs.
- ClaimIntelligence™
- CLEAR™
Products and services
- FOCUS™ (Fiduciary Oversight, Compliance & Utilization Safeguard)
Quantifiable outcome
- $500-$1,200 per employee per year in measurable ROI
- +4 more outcomes
Companies that use ClaimInformatics
Customer profileNamed customers2 records
Segments4 records
Ideal customer profiles2 records
ClaimInformatics technology and API
TechnologyTechnology focussed Yes
API detail
- Has API
- No
- API docs
- API detail
Core technology
AI maturity
App detail
Feature5 records
ClaimInformatics partnerships and signals
Strategic signalPartnerships
One partnership is on record.
- Detego HealthcorePartnership to improve claims processing transparency and accountability by separating fiduciary oversight from payment operations for self-funded health plans. The integrated platform is now operational across Detego Health's nationwide networks. Collaboration aims to address conflicts inherent in traditional models, reducing costs, administrative burden, and enhancing compliance for plan sponsors.
Scale indicators7 records
Recent moves6 records
Expansion highlights6 records
ClaimInformatics competitors and assessment
Company assessmentEmerging players
- Clarify Health: Clarify Health is a healthcare analytics platform offering payment integrity, value-based care, and network design analytics. It is an emerging peer with overlapping analytics-driven payment integrity capabilities but broader horizontal scope beyond self-funded fiduciary oversight.
Direct peers
- Hines & Associates: Hines & Associates provides independent medical bill review, utilization management, and payment integrity services to TPAs and self-funded plans. It is directly comparable to ClaimInformatics' independent, conflict-free positioning vis-à-vis TPAs and networks.
- Cotiviti: Cotiviti is one of the largest independent payment integrity and claims editing vendors, applying proprietary edit logic to identify overpayments across medical and pharmacy claims. It is the closest direct competitor to ClaimInformatics' ClaimIntelligence Edit Suite and recovery services for self-funded plans.
- Pareto Intelligence: Pareto Intelligence is a healthcare analytics and payment integrity firm focused on identifying overpayments, coding accuracy, and contract compliance for payers and self-funded employers. Its offerings closely mirror ClaimInformatics' post-pay and ongoing monitoring capabilities.
- Performant Financial Corporation (Healthcare): Performant provides healthcare payment integrity and recovery audit services, identifying improper payments and coordinating recoveries from providers. It is directly comparable to ClaimInformatics' transparent recovery model and ongoing monitoring value proposition.
- Lyric (formerly ClaimsXten): Lyric, the rebranded ClaimsXten business, provides claims editing software used by payers and TPAs to validate coding and detect billing errors before payment. It competes directly with ClaimInformatics' pre-pay ClaimIntelligence Edit Suite at the rule-engine layer.
- SCIO Health Analytics (now part of emids): SCIO provides payment integrity, risk adjustment, and care management analytics to payers and providers. Its payment integrity offerings are directly comparable to ClaimInformatics' claims review and recovery services for self-funded plan sponsors.
Others
- Datavant: Datavant provides health data exchange and de-identification infrastructure used across the healthcare ecosystem. While not a payment integrity competitor, it is an adjacent enabling technology provider whose data connectivity capabilities intersect with how payment integrity platforms like ClaimInformatics ingest and analyze claims data.
Broad incumbents
- Optum (Change Healthcare): Optum, part of UnitedHealth Group, absorbed Change Healthcare and operates one of the largest payment integrity franchises, offering claims editing, subrogation, and recovery at massive scale. It represents the dominant incumbent that ClaimInformatics competes against in self-funded plan oversight.
- MultiPlan: MultiPlan is a large cost-containment and payment integrity vendor serving payers, TPAs, and self-funded plans with network and out-of-network claim review services. It overlaps with ClaimInformatics on overpayment identification but serves a much broader set of buyer segments.
Market position
Strengths5 records
Weaknesses5 records
Competitive moat5 records
Key risks6 records
Key highlights7 records
Customer concentration
ClaimInformatics social profiles
Digital presenceClaimInformatics compliance and trust
Trust signalCompliance2 records
ClaimInformatics financial estimates
Financial estimateRevenue estimate
Valuation estimate
ClaimInformatics leadership team
Management profileNumber of profiles
Profiles5 records
ClaimInformatics funding detail
Funding detailFunding overview
Funding rounds4 records
Investors
Funding detail is available on the Subscription and Enterprise plan.Contact sales →
ClaimInformatics M&A and investment
M&A and investmentM&A
Investments
M&A and investment is available on the Subscription and Enterprise plan.Contact sales →
Frequently asked questions about ClaimInformatics
What does ClaimInformatics do?
ClaimInformatics develops a HIPAA-compliant, SOC 2 Type II certified payment integrity and fiduciary compliance platform that discovers and recovers improper payments on behalf of self-funded and captive health plan fiduciaries, employers, TPAs, and benefits brokers. The platform combines its proprietary FOCUS™ framework with a 850+ rule ClaimIntelligence™ Edit Suite to deliver pre-pay edit validation, ongoing monthly claims monitoring, and a 50/50 transparent recovery model. Data is exchanged via secure SFTP using EDI 834, 835, 837, CSV, and pipe-delimited file formats.
Is ClaimInformatics a public or private company?
ClaimInformatics is a private company. It is currently operating.
When was ClaimInformatics founded?
ClaimInformatics was founded in 2017. It employs 11 to 50 people.
Where is ClaimInformatics based?
ClaimInformatics is headquartered in Bloomfield, United States, in the North America region.
How does ClaimInformatics make money?
Two revenue lines are on record. Recovery Revenue Sharing is the primary driver. The others are ongoing Monitoring Services.
Who are ClaimInformatics's main competitors?
Clarify Health is listed as an emerging player. Direct peers are Hines & Associates, Cotiviti, Pareto Intelligence, Performant Financial Corporation (Healthcare), Lyric (formerly ClaimsXten) and SCIO Health Analytics (now part of emids). Datavant is listed as an others. Broad incumbents are Optum (Change Healthcare) and MultiPlan.
Does ClaimInformatics have an API?
No public API is recorded for ClaimInformatics.