OMAHA, Neb., Sept. 09, 2026 (GLOBE NEWSWIRE) — ClaimQI, Inc. (pronounced Claim-Chee), a healthcare claims intelligence company, today announced the launch of the ClaimQI Platform and its new Payer Portal, purpose-built to help payers identify and prevent fraud, waste, and abuse (FWA) before it erodes plan cost and quality performance. The announcement was made from the Healthcare Payment & Revenue Integrity (HPRI) Congress in Chicago, where ClaimQI is serving as a Community Partner.
Most FWA tools on the market today were built toward statistical anomaly detection, flagging claims and providers whose behavior deviates from historical norms, then requiring human review. This is important in fraud risk detection but leaves the other 95% of claims left unattended. ClaimQI takes a different approach. The ClaimQI patent-pending platform validates every claim against deterministic coverage rules, codes, and policy language that govern at that time, producing time-specific, citation-backed determinations and explanations. The result is a defensible determination a health plan can trace back to a specific policy citation, not just a probability score to interpret and defend after the fact.
“Medicare plans don’t just need to know that a claim looks wrong, they need to know exactly why, and they need that answer to hold up the same way every time,” said Chad Wells, President and CEO of ClaimQI. “We built ClaimQI because the industry needed a sophisticated and consistently defensible approach to identifying improper claims and payments. The waste that matters most is often hiding in claims that look completely ordinary but simply don’t comply with the rules that govern them. That’s the harder problem, and it’s the one we set out to solve first.”
The new ClaimQI Payer Portal gives payers and/or their administrators a direct, self-service view into ClaimQI’s findings without needing to interpret a black-box risk score. Key capabilities include:
- Configurable adjudication tolerance for rule adherence that lets payers modify adjudication controls based on their own risk tolerance, choosing whether specific rule configurations can accept an automatic Deny or require personnel Review
- Simple claims analysis that automatically summarizes every run by outcome as improper, needing review, or passed, and giving payers an immediate read on a book of claims
- Improper claim grouping by root cause, surfacing the most common rules a run of claims failed on and the providers behind them, so recovery operations and SIU teams can group and prioritize investigations rather than working claim-by-claim
- Explicit black-and-white rule citations and explanations versus paraphrased summaries or ambiguous black-box explanations. Every improper claim shows the exact rule(s) it failed, quoted directly from the governing source document, with links to the source articles, furthering recovery efforts, legal support, and audit tracking
- Dollar-level transparency on claims dollars identified, whether caught pre-payment or flagged for post-payment recovery
- Policy-accurate historical review, past claims are assessed against the coverage rules that existed on their own claim date, with policy rule updates traced to their effective dates, so a claim is always judged by the rules that actually governed it at that time
“Payers have told us they’re tired of chasing down why a model flagged something and concerned about the risk involved,” said Janna Hart, Chief Operating and Product Officer of ClaimQI. “The Payer Portal was built around that feedback. Every improper claim comes back with the exact rule it failed, quoted word-for-word from the source policy, with a link back to the article itself. That’s not just a finding our customers have to take on faith, it’s evidence their recovery, legal, and audit teams can use immediately.”
ClaimQI’s Platform is Organized Around Three Modules:
- ClaimQI Core – the primary engine driving ClaimQI, validates every claim against coverage rules and policy logic, and provides detailed black-and-white, citation-backed explanations and determinations
- ClaimQI Prevent – run stand alone or enhanced with ClaimQI Core, surfaces and prioritizes claim trends and anomalies, and provides predictive, probabilistic risk-scoring on case outliers
- ClaimQI Insights – gives payers and/or administrators visibility into their entire claims book for broader intelligence on trends, impacts and opportunities across all providers and lines of business.
The company’s architecture keeps claims data itself out of any AI model at the point of injection and decision. Large language models (LLMs) are not used in the processing path and instead used to translate published coverage policy into deterministic, executable rule logic. This approach is designed to allow consistently accurate, thorough documentation about the claim results while ensuring protected data never enters the LLM dataset, avoiding risk of AI-generated drift or interpretive hallucination. This unique approach is intended to hold up under the AI governance and documentation requirements now in effect across a majority of U.S. states and is the subject of a pending U.S. patent application.
ClaimQI runs on an Amazon Web Services HIPAA-compliant technology stack, with data-privacy and security-first frameworks engineered into the platform’s architecture, with SOC 2 certification currently in progress.
The platform launch follows yesterday’s announcement of ClaimQI, Inc. closing its seed funding round at just under $500,000. The company has also been awarded a pending $150,000 matching grant from the Nebraska Department of Economic Development (NE DED), capital the company is putting directly toward scaling the ClaimQI Platform and Payer Portal.
ClaimQI will be available at the HPRI Congress, September 9–10, 2026, at the Radisson Blu Aqua Hotel in Chicago, where the team will be on-site as a Community Partner throughout the event. Attendees can visit them at booth #1.
Website: www.claimqi.ai for additional information.
About ClaimQI, Inc.
ClaimQI, Inc. is a healthcare claims intelligence company delivering fraud, waste, and abuse (FWA) prevention for health plans across Medicare Advantage, Medicaid, Medigap, and self-funded ERISA markets. Rather than leading with claims scoring on probabilistic risk and statistical anomaly detection, ClaimQI validates every claim against deterministic coverage rules, codes, and policy language, producing defensible, citation-backed determinations that avoid AI-inherent risks. ClaimQI’s underlying AI/LLM methodology, which produces this citation-driven output while keeping claims data itself out of the AI model, is the subject of a pending U.S. patent application. ClaimQI was founded by Chad Wells and Janna Hart, whose combined more than 50 years of experience spans executive leadership at health plans and payers, claims, compliance, and Special Investigations Unit (SIU) operations. ClaimQI is headquartered in Omaha, Nebraska. Learn more at www.ClaimQI.ai.
Contact
Chad Wells
ClaimQI
[email protected]
A photo accompanying this announcement is available at https://www.globenewswire.com/NewsRoom/AttachmentNg/2db04c81-a0d3-412f-9e3e-66345be92116
