Care Operations That Produce
The Same Answer Twice.
Prior authorization, claims adjudication, and eligibility decisions evaluated as symbolic rules — checked before they run, redacted before they leave your environment, and signed with a Cognitive Trust Certificate a compliance officer can hand to an auditor.
Pick the Path That Matches Your Organisation
Provider and payer teams work the same transactions from opposite ends. Each path gets its own vocabulary below — both converge on the same deterministic core, the same proof, and the same audit trail.
Where AI Breaks in Provider Operations
The denial is rarely the problem. The problem is that nobody can say which rule produced it, or why the same claim got a different answer the second time.
Prior auth decided by a paragraph
An authorization outcome arrives with a rationale and no rule behind it. When the denial is appealed, the answer to "why was this denied?" is prose, not a criterion anyone can point at.
Denials worked twice
The same claim gets re-reasoned on every touch, producing a different appeal strategy each time and no diff against what was already tried.
Coding rules treated as suggestions
Medical-necessity and bundling rules end up as instructions in a prompt, where the constraint that mattered most quietly loses to everything else in the context window.
Re-work billed at token prices
Every retry and re-read of a claim costs money, and finance sees the invoice with no attribution back to the queue or the workflow that caused it.
What You Can Put Into Production
Deterministic rules in front of the work that generates denials.
Prior Authorization With Deterministic Rules
Medical-necessity criteria and payer-specific requirements held as symbolic constraints, so the same request is evaluated the same way twice and a denial cites the criterion that failed.
- Payer rules stored as constraints, not prompt text
- Denials cite the criterion that fired
- PHI redacted before it reaches a model
Related Solutions
Claims and Denials Management
Coding edits, bundling checks, and appeal routing run in-process against structured claim data — no hallucinated modifier, no re-derived answer between touches.
- Edits and bundling checks computed without a model call
- Appeal paths reproducible across every touch
- Itemized receipts per call, attributed to the queue
Related Solutions
Eligibility and Benefits Verification
Coverage and benefit joins across eligibility, payer, and scheduling systems on a shared identity key — verified against structured data rather than a model's recollection.
- Deterministic joins with zero token cost
- Type bridging across payer and EHR systems
- Same member, same answer, on every run
Related Solutions
Patient Scheduling and Referral Routing
Slots, specialties, and referral requirements modelled as constrained resources, so a booking that breaks a rule is blocked rather than discovered at check-in.
- Double-booking prevented before the slot is written
- Referral requirements as blocking constraints
- Cancellations trigger a bounded, deterministic re-plan
Related Solutions
What Stays Probabilistic — and What We Make Provable
We do not claim the model becomes deterministic. We separate the two: the agent reads the request, and everything that has to survive an audit is evaluated symbolically, verified before execution, and signed after it.
- Reading a clinical note, a claim attachment, or a member request
- Drafting the rationale a reviewer or a member reads
- Recognizing that a case needs clinical review at all
- Medical-necessity criteria, coding rules, and payer requirements live in Logic and Batteries — evaluated symbolically in sub-millisecond time, and able to block a step before it runs
- Approval gates halt a determination or a payment until a named human signs off
- Every plan is verified cycle-free, type-safe, policy-compliant, and credential-complete before execution
- Cognitive Trust Certificates are signed with Ed25519 by the DataGrout Certificate Authority — compile-time assurance plus runtime confirmation
- PHI is detected and redacted before it ever reaches the model's context
- Every action lands in a complete execution audit trail carrying its cost and its authorizing identity
A determination cannot be written until it is provable — and once it runs, the proof is signed.
The Evidence Your Compliance Officer Will Ask For
Four artifacts that turn an agent action into something an auditor can accept.
Signed proof of every approved decision
Each verified plan receives a Cognitive Trust Certificate — a cryptographic attestation signed with Ed25519 by the DataGrout Certificate Authority, asserting the plan is cycle-free, type-safe, policy-compliant, credential-complete, and deterministic.
A complete execution audit trail
Every tool call is authenticated, authorized, and logged with its cost and the identity that authorized it. An audit request is answered from history — who touched the claim, under which policy, against which system — rather than by rebuilding it.
PHI redacted before the model sees anything
PII and PHI auto-detection masks names, addresses, dates of birth, member identifiers, and card numbers, with field-level strategies from scramble to fixed-length masking applied after execution and before the response reaches the agent.
Policy enforced at the infrastructure layer
Semantic guards validate every call before it reaches the upstream system. A violating call is rejected with a stated reason rather than silently passed through, and side-effect limits bound what any agent can do at all.
Budgets and loop detection as controls
Caps are enforced at call time, so a budget is a control rather than a report. Consequence-aware loop detection distinguishes a genuine retry from a spiral that is only burning credits on an authorization queue.
Evidence that survives review
Cached results are encrypted at rest with AES-256-GCM and scoped to the user. Documents are version-tracked. The chain from request to determination stays intact long after the run.
Who This Page Is For
The same platform, read through the lens each stakeholder is accountable for.
CIO
Owns rollout across clinical, revenue cycle, and payer-facing systems, and the vendors behind them.
CISO
Owns PHI handling, the policy cascade, and the identity model behind every agent touching member data.
CTO
Owns the gateway, the EHR and claims integrations, and the workflow surface agents run on.
CFO
Owns the cost of re-work and re-adjudication, and whether that number is forecastable.
Where It Runs and What It Touches
Designed for environments where PHI handling has to be specific, not aspirational.
On-premise and private cloud
Private Connectors reach on-premise EHR, claims, and eligibility systems through outbound-only mTLS tunnels — no inbound firewall ports, each connector isolated and single-tenant, with VPN support for NetBird, WireGuard, and OpenVPN. Typical latency overhead is 10–30ms.
PHI redaction as a control, not a policy
Auto-detection runs on the way out of every call and masks sensitive fields before they reach a model's context, with field-level strategies you set per integration. Redaction is executed by the platform on each call rather than documented in a procedure.
Your models, your keys
Bring your own model provider keys and pay your provider directly. DataGrout takes no markup on inference, and no PHI is required to leave your environment for the platform to work.
An audit trail you can hand over
Execution history, signed certificates, and itemized receipts are retained as records a privacy officer, compliance function, or external auditor can review without asking engineering to reconstruct anything.
Start With the Systems You Already Run
Connect through the DataGrout MCP server — or bring any MCP-compatible system of your own.
The Questions Your Privacy Officer Will Ask
Straight answers, because these are the objections that stall the deal.
Also working in a neighbouring vertical?
The same deterministic core carries the same signed proof — into insurance, banking and finance, and operations.
Bring Us Your Hardest Clinical Rule
Bring the criterion your reviewers argue about — a medical-necessity rule, a coding edit, an authorization threshold. We will walk through how it is enforced symbolically, what the PHI handling looks like on the wire, and how the determination is signed and logged.
Book Your DataGrout Demo
See real-time cost visibility, budget controls, and audit trails — tailored to your enterprise stack.