MClaimIQ's AI evaluates every claim against the insurance policy wording, medical protocols and approved rate benchmarks — then generates a complete claim report with a decision recommendation. The human agent reviews and decides. Or for clear-cut claims, the system resolves automatically. Every time, in minutes.
Every claim — medical or non-medical — passes through MClaimIQ's structured AI pipeline. Evaluated in seconds. Confirmed by a licensed expert. Resolved within SLA.
Licensed physicians validating complex international claims 24/7
Real-time ICD-10 coding and DRG benchmarking
Direct partnerships across 70+ countries worldwide
Protecting travellers across every continent
Benchmarking against 35+ local DRG rate systems
MClaimIQ's AI engine does not replace human expertise — it makes it faster, more consistent and more profitable. Here is exactly what happens inside every claim evaluation.
The moment a claim is submitted, the AI ingests every attached document — hospital invoices, discharge summaries, surgical and lab reports, medical certificates, boarding passes, receipts and PIR reports. OCR powered by transformer-based models extracts structured data from unstructured documents in 20+ languages. Every diagnosis term, procedure code, cost line item, date and provider reference is parsed into a standardised claim record within seconds — creating the data foundation for every evaluation step that follows.
The AI reads the insurer's specific policy wording for this insured and evaluates the claim against it precisely. It checks: whether the diagnosis and procedure are within the scope of covered benefits, which benefit limits and sub-limits apply to this claim, whether any general or specific exclusions are triggered by the clinical facts, what waiting period conditions or pre-existing condition clauses may be relevant, and what documentation requirements the policy demands for this claim type. The policy wording is not applied as a generic rule set — it is read and interpreted for each specific case, generating a coverage determination with exact policy clause references for every finding.
The AI evaluates the medical case against established clinical protocols and evidence-based treatment guidelines. It assigns ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes from the clinical documentation and verifies that the treatment performed is clinically appropriate for the confirmed diagnosis — that the length of hospital stay is consistent with the procedure, that the procedures billed match what the clinical notes describe, and that the complexity and severity coding reflects the documented clinical evidence. Upcoding, unbundling and medically unjustified procedures are flagged with specific clinical references. This step ensures the claim is assessed not just against what was billed, but against what was medically warranted.
Every line item on every invoice is evaluated. For medical claims, each procedure and accommodation charge is benchmarked against the locally approved DRG rate for the country of treatment — across 35+ national DRG systems. Charges above the approved rate are flagged with the exact excess figure and the DRG code reference. For pharmaceutical and consumable items, unit prices are checked against market reference databases. For travel and non-medical claims, invoices are validated against fare databases, market rates, depreciation schedules and policy per-diem limits. The fraud detection model simultaneously screens all invoices for duplicate billing, inflated prices and inconsistent documentation patterns. The output is a fully itemised cost evaluation showing the approved payable amount for every single charge.
The AI compiles a complete, structured claim evaluation report containing: the coverage determination with exact policy clause references, the ICD-10 and DRG codes with clinical justification, the itemised invoice evaluation with approved vs billed amounts for every line, the fraud score and any risk flags raised, and a clear payment recommendation with the authorised amount. This report is delivered to the human agent — a licensed physician or senior claims handler — who reviews the AI findings, applies professional judgement to any complex or disputed elements, and takes the final decision. For clear-cut, low-complexity claims that meet all policy conditions with no flags raised, the system can auto-resolve and authorise payment without human intervention, within the parameters defined by the insurer. Every decision — human or automated — is logged in a full, timestamped audit trail.
MClaimIQ is built for two operating modes. In assisted mode, the AI generates a complete evaluation report and hands it to a human agent — a licensed physician or senior claims handler — who reviews the findings, applies professional judgement and takes the final decision. The agent does not start from scratch; they start from a fully structured, evidence-backed recommendation that typically takes minutes to review rather than days to build.
In straight-through processing (STP) mode, the system resolves and authorises payment automatically for claims that meet all policy conditions, carry no fraud flags, fall within the DRG approved rate and require no clinical judgement call. The insurer defines which claim types and value thresholds qualify for STP. Every automated decision is logged with the full evaluation trail — policy references, clinical codes, cost comparison and fraud score — so it is fully auditable and defensible.
The AI does not decide arbitrarily. Every output is grounded in three documented sources: the insurer's policy wording, established medical protocols and approved rate benchmarks. The human agent — or the STP engine — acts on that structured evidence, not on a black-box score.
Our AI engine is trained on 12,000+ real international medical claims and validated by licensed physicians. It reads reports, assigns ICD-10 codes, cross-references policy coverage and detects fraud — in under 60 seconds.
Enter any medical claim amount and see exactly how much MClaimIQ's DRG benchmarking would save your organisation.
AI assigns correct DRG code from diagnosis and procedure data
Retrieves approved DRG rate for the hospital's country and region
Any billing above DRG rate flagged with exact overage amount
Insurer pays the DRG-approved amount only — savings captured automatically
Enter a claim amount, select a diagnosis and country, then click Calculate to see your DRG savings analysis.
Most hospitals in travel and IPMI markets bill well above the locally approved DRG rate. Without benchmarking, insurers pay the billed amount. With MClaimIQ, every inpatient claim is measured against the official DRG rate — and every euro of excess is recovered.
In Greece, Turkey and Southern Europe, hospitals routinely bill 20–35% above the approved DRG rate for inpatient procedures. MClaimIQ identifies the exact excess on every single claim.
A single cardiac claim can carry €2,000–€8,000 in recoverable excess. Across a portfolio of 500 inpatient claims per year, DRG benchmarking typically saves insurers €350K–€900K annually.
Every DRG payment decision is confirmed by a licensed physician and backed by a complete audit trail referencing the official national DRG rate schedule — fully defensible to hospitals and regulators.
MClaimIQ covers G-DRG (Germany), GHM (France), HRG (UK), MS-DRG (USA), GR-DRG (Greece), AP-DRG (Turkey) and 29 more — quarterly updated with official rate tables.
Actual claim data across common inpatient procedures in the Greek and Turkish markets
Our global network means we can validate and coordinate any claim, anywhere — with local DRG rates, local medical expertise, and local language support always available.
Every capability built for the full complexity of global insurance — travel, health, IPMI, marine, property and liability.
Our AI engine uses transformer-based NLP to read every clinical document — discharge summaries, surgical reports, lab results — in over 20 languages. It extracts diagnoses, procedures and cost line items, maps them to ICD-10 codes, cross-references the insured's policy terms and produces a structured decision recommendation within 60 seconds of claim submission.
The model is continuously retrained on new resolved claims, improving accuracy with every case. Available 24/7 with no capacity ceiling — processing a single urgent claim or a batch of 500 with identical precision and zero fatigue.
Our ML fraud model evaluates 40+ risk signals simultaneously: duplicate invoice detection across providers, billing frequency anomalies, diagnosis-treatment mismatches, date inconsistencies between travel and medical documents, and sudden shifts in a hospital's billing pattern.
Provider risk scores are maintained from 25 years of claims history. Policy inception proximity scoring flags claims filed within days of activation. High-risk claims are held for enhanced human review with a detailed fraud risk report. Cleared claims carry a fraud score in the full audit trail.
MClaimIQ's DRG grouper assigns the correct DRG code from confirmed ICD-10 codes, then retrieves the nationally approved payment rate — the same rate used by the country's public health system to pay that hospital for the identical treatment. The hospital's billed amount is compared against this official rate to the cent.
Any excess is flagged with the exact overage figure, the percentage above rate and the specific line items driving the inflation. Payment is recommended at the DRG-approved rate only. Systems covered include G-DRG, GHM, HRG, MS-DRG, GR-DRG, AP-DRG, AR-DRG, SDO-DRG and 27 more — all updated quarterly with official government rate schedules.
MClaimIQ's NLP reads clinical text in its original language and assigns the correct ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes. The AI detects upcoding (billing for a more complex procedure than performed), unbundling (splitting one procedure into multiple billed codes) and phantom diagnoses (adding secondary codes purely to inflate DRG weight).
All AI-assigned codes are confirmed by a licensed physician before being used as the payment basis. This physician-in-the-loop model means every coding decision is both algorithmically consistent and clinically defensible. Covers ICD-10-CM, ICD-10-PCS and WHO ICD-10 with all major national extensions.
Our network includes direct cost containment agreements with 4,800+ hospitals across Europe, the Middle East, Africa, Asia Pacific and the Americas. For every country, we maintain the current official DRG rate schedule and a physician panel for expert medical review in the local language.
Network coordinators can contact hospitals directly on behalf of insurers: to negotiate final bills, request missing medical records, arrange direct billing and resolve disputes. For out-of-network hospitals, our team can source local DRG benchmarks and arrange expert review within 24 hours. 24/7 intake — no geographic limitation.
When a hospital requests a GOP before proceeding with treatment, MClaimIQ evaluates the request and returns a decision within SLA — typically 2–4 hours for standard cases, faster for emergencies. The AI calculates the expected DRG cost for the proposed treatment, verifies policy coverage and limits, applies exclusions and determines the maximum payable amount.
The GOP is issued at the DRG-approved rate — not the hospital's quoted figure. This prevents overbilling from the first moment of care rather than recovering excess after invoices are paid. Every GOP carries the specific DRG code, applicable rate and clinical basis for the authorisation, creating a fully auditable pre-payment record.
Hospital invoices, discharge summaries and surgical notes arrive in the language of the country where treatment occurred. MClaimIQ processes Arabic, French, German, Spanish, Italian, Greek, Turkish, Russian, Polish, Dutch, Portuguese, Romanian, Serbian, Croatian, Hebrew and more natively — without external translation services that add cost, delay and terminology error risk.
Medical terminology is parsed in its original language. ICD-10 code mapping covers clinical terms across all supported languages, ensuring a diagnosis written in Arabic or a procedure listed in Greek is coded with identical accuracy to an English document. Identical processing time and cost regardless of document language.
MClaimIQ connects to your existing claims management system via a fully documented REST API. Claims are submitted programmatically and structured decision responses — ICD-10 codes, DRG assignment, approved payment amount, fraud score — are returned in real time. Webhooks push status updates (received, under evaluation, decision ready, payment authorised) to your system automatically.
Full claims data and decision history are available via our web dashboard for reporting, auditing and portfolio analysis. Supports integration with major TPA platforms, insurer core systems and assistance company software. ISO 27001 certified. GDPR-compliant for EU operations. HIPAA-ready for US markets. Dedicated technical integration support for all clients.
MClaimIQ was founded in 2000 as a medical assistance and cost containment service for international insurers operating in Greece and the Eastern Mediterranean — a region historically characterised by high hospital billing rates and limited cost control infrastructure. Over 25 years we built direct hospital relationships, a 15,000+ physician network and 46+ active insurer accounts across 70+ countries.
The AI engine is trained on 25 years of real resolved claims — including complex disputed cases, proven fraud schemes, successful cost recovery negotiations and the full clinical complexity of international insurance. This is not a technology company that learned about insurance from textbooks. Every algorithm reflects decisions made by licensed clinicians and senior claims professionals with decades of hands-on international experience.
For flight delay and cancellation, the AI reads delay certificates, validates alternative transport invoices against fare databases and applies the policy delay threshold per person. For baggage claims, it cross-references PIR reports, purchase receipts and applies depreciation and per-item limits. For trip cancellation, it verifies prepaid non-refundable costs and confirms the insured event against the policy's covered events list.
For personal liability abroad, it assesses third-party quantum, validates legal invoices and applies the liability limit and policy excess. Every non-medical claim is processed against the insurer's specific policy wording — not a generic rule set — and confirmed by a licensed claims handler before any payment is authorised. Same SLA and audit trail standards as medical claims.
From flight disruption to emergency medical abroad — MClaimIQ evaluates every travel claim with AI precision, invoice validation and licensed human sign-off.
From medical review rooms to global networks — a glimpse into our operations.
Real outcomes from real insurer partnerships — validated by data, not marketing.
Medical. Non-medical. Travel. Health. Marine. Liability.
MClaimIQ handles every class of insurance claim — with AI speed and human precision.