Claims adjudication assistant
A kolm template that classifies claims as Approved / Denied / Pending with concise clinical and policy reasoning in your company voice. PHI is redacted before any inference. The decision schema is fixed, the K-score gate is locked at 0.95, and every call ships a 4-ring HMAC receipt your auditor can re-verify offline.
Input & output spec
A claim adjudication request is one JSON object per claim. The output schema is fixed; downstream systems can rely on the field names and types without re-parsing.
input
{
"claim_id": "CLM_2026_0481923",
"member_id": "<redacted>",
"provider_npi": "1234567893",
"service_date": "2026-05-09",
"cpt_codes": ["99214", "93000"],
"icd10_codes": ["I10", "E11.9"],
"billed_amount": 189.40,
"plan": "PPO-Gold-2026",
"prior_auth_ref": null,
"notes": "<clinical-summary>"
}
output
{
"decision": "Approved", // or "Denied" / "Pending"
"reason": "Routine office visit + EKG, both covered under PPO-Gold. No prior-auth required for CPT 99214/93000 under plan rules.",
"confidence": 0.94,
"policy_refs": ["PPO-Gold-2026 §3.2", "CPT-99214-rule"],
"redaction_count": 3,
"requires_review": false
}
4-ring receipt schema
Every decision ships a receipt your auditor can re-verify offline. No frontier API call goes uncaptured; the chain proves the inputs, the policy mapping, the decision, and the seal.
Verify command: kolm verify --hash <receipt_hash>. Runs locally against the seal, no network required.
BAA fast-track
Health plans on a BAA see kolm production-ready in two business days. The customer-hosted bridge runs in the tenant network boundary; PHI is processed there and never crosses our infrastructure; the audit log is yours to keep.
how it works
# 1. Sign the BAA (legal-team turnaround) [ DocuSign · 48 hours typical · mutual NDA in same envelope ] # 2. Provision the bridge in your VPC $ kolm bridge install \ --provider aws \ --region us-east-1 \ --baa <baa-id> # 3. Compile this template against your seed examples $ kolm compile --spec claims-adjudication.spec.json \ --examples ./your-anonymized-claims.jsonl \ --gate 0.95 \ --out claims.kolm
what we sign
- HIPAA Business Associate Agreement - HIPAA Security Rule §164.308 (admin safeguards) - HIPAA Security Rule §164.310 (physical safeguards) - HIPAA Security Rule §164.312 (technical safeguards) - Breach Notification §164.404 - Subcontractor flow-down (none — kolm holds no PHI) - Audit-log retention (6 years, your S3 bucket)
Get the template
Two ways to take this live. Self-serve with the sample artifact, or kick off a BAA conversation if you need PHI day one.
The spec is a portable JSON file. Drop it into kolm compile --spec with your anonymized seed examples to build a private .kolm tagged LicenseRef-kolm-default-1.0 by default; pass --license to tag it differently.