Alaffia Health
AI-powered payment integrity platform for health plan claims operations
Overview
Alaffia Health is a payment integrity platform for health insurance payers, delivering AI-driven tools to detect and eliminate fraud, waste, and abuse in healthcare claims management. The company serves regional and national health plans across the US, with a focus on reducing the estimated USD 570 billion in annual healthcare administrative waste.
The platform uses agentic AI with human validation workflows to support clinical review across the full claims lifecycle. Core capabilities include forensic evaluation of medical claims against patient medical records, automated clinical reasoning with citations, and configurable AI agents that integrate with existing health plan systems via API. The platform is HIPAA compliant, SOC-II Type II certified, and HITRUST compliant.
Founded in 2020, Alaffia has raised over USD 73M in funding, including a USD 55M Series B in February 2026 led by Transformation Capital. The company reports customer outcomes including 20x throughput improvement, 97%+ accuracy rates, 5x ROI, and USD 21M in documented cost savings across its customer base.
Products & Services
Auto Agents
AI-powered automation for scaling clinical claims review workflows. Custom-built AI coworkers designed to increase clinician claim review throughput by up to 20x while maintaining clinical accuracy and consistency.
Key Features
- Agentic AI with human validation workflows
- Medical records normalization and clinical fact extraction
- Traceable reasoning with citations for each determination
Target Users: Health plan clinical review teams
AUTODOR AI Agents
Specialized AI agent product for healthcare claims processing, launched in April 2025. Designed for high-volume DRG coding optimization and claim validation.
Key Features
- DRG (Diagnosis Related Group) coding optimization and validation
- Forensic evaluation against complete patient medical records
- Integration with health plan billing and revenue cycle systems
Target Users: Health plan payment integrity and clinical operations teams
Utilization Management
Clinical necessity review automation for care requests and claims, reducing manual burden on clinical review teams.
Key Features
- Automated prior authorization and concurrent review
- Clinical necessity evaluation across inpatient and outpatient settings
- Configurable workflows for health plan protocols
Target Users: Health plan utilization management departments
Appeals Processing
Automated claims appeal management to accelerate resolution timelines from weeks to days.
Key Features
- Automated appeal intake and clinical review
- Evidence-based determinations with full audit trail
- Integration with payer adjudication systems
Target Users: Health plan appeals and grievance departments
Case Management
Clinical case review automation for complex patient cases and high-cost claims.
Key Features
- Complex case identification and routing
- AI-assisted clinical review with full documentation
- Coordination across care teams and payer workflows
Target Users: Health plan case management and medical management teams
Special Investigations
Fraud investigation support with detailed forensic analysis of suspicious claims patterns.
Key Features
- Pattern detection across claims populations
- Forensic medical record analysis
- Structured case documentation for payer SIU teams
Target Users: Health plan special investigations units
At a Glance
- Founded
- 2020
- Headquarters
- United States
- Employees
- 51-200
- Funding
- Series B
Category & Focus
- Category
- Claims Technology
- Subcategories
- Payment Integrity Fraud Detection Claims Automation Utilization Management
- Insurance Verticals
- Health
- Target Customers
- Carriers, TPAs
Customers
- Regional and national health plans (US)
Links
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Last updated: 2026-06-15