AI Claims Orchestration · MENA

Every missed fraudulent claim erodes your loss ratio.
iRonic Health is built to flag it in under 5 seconds.

The current platform connects the prescribing physician and the payer; the other parties of the ecosystem are added along the roadmap.

AI-powered claims orchestration and fraud detection for Egypt's private health insurance market. Built for insurers, TPAs, and the FRA compliance era.

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Model target · pilot scenario
0×target return on subscription
87% auto‑approval target
Platform Overview
DEMO
LOSS RATIO
68.2%
↓ 9.9pp improvement
FRAUD RECOVERED
EGP 842K
↑ 18% vs last month
Loss Ratio Trend — 2026−9.9pp
CLM‑48471auto‑approved · EGP 18.4K
CLM‑48469flagged · drug splitting
MBR‑19847eligibility verified · 3.9s
0
target ROI on platform subscription
0
target auto‑approvals in under 5s
0
target loss‑ratio reduction
0
fraud archetypes across 6 categories

Model targets pending pilot validation. Figures shown in product views below are illustrative demo data.

Built & tested
Clinical rules engine (diabetes scope) and physician workbench
How it works

One intelligent layer over your entire claims ecosystem

01

Connect

In the build pipeline

Every party in your claims ecosystem connects through one intelligent layer: insurers, TPAs, hospitals, pharmacies, labs, and physicians.

02

Analyze

In the build pipeline

Every claim is scored in real time against 31 fraud archetypes. Suspicious patterns are flagged instantly. Clean claims are approved automatically.

03

Control

Designed · Coming next

Full FRA‑ready audit trail. Complete visibility. Zero blind spots across your entire claims portfolio.

The operator console
Interactive prototype

Watch a claim get analyzed, decided, and documented

The Platform Overview your CFO, CMO, and TPA operators work in — shown here with illustrative demo data.

iRonic Health
Operator Dashboard
⚡
AI Experience
Fraud Detection Demo
PLATFORM
▦Overview
▤Claims127
⚠Fraud Detection23
℞Pharmacy
◎Members
INTELLIGENCE
▥Reports
⛨FRA Compliance✓
◍API Status
Platform Overview
Demo environment · illustrative dataCFO
LOSS RATIO
68.2%
↓ 9.9pp improvement
FRAUD RECOVERED MTD
EGP 0K
↑ 18% vs last month
PLATFORM ROI
0×
↑ Q2 YTD
ACTIVE MEMBERS
125,000
↑ 12K onboarded Apr
Loss Ratio Trend — 2026−9.9pp YTD
80%73%65% JanAprJun
Net savings (illustrative)EGP 2.1M
Real‑time Activity● Demo
CLM‑48471 auto‑approved · Hospital A · EGP 18.4K
CLM‑48469 flagged · drug splitting detected
MBR‑19847 eligibility verified via QR · 3.9s
CLM‑48465 rejected · duplicate submission
Recent Claims — AI Decisions
CLAIM IDPROVIDERAMOUNTAI SCOREDECISION
CLM‑48471Hospital AEGP 18,4000✓ Approved
CLM‑48469Hospital BEGP 3,2000⚠ Flagged
H
AI Claim Analysis
CLM‑26‑48469
PROVIDER
Hospital B
AMOUNT
EGP 3,200
TYPE
Pharmacy
AI CONFIDENCE
91%
0
/ 100 risk score
⚠ CMO Review Required
FRAUD ARCHETYPES DETECTED
Drug SplittingPrescription Volume Anomaly

Every claim. Analyzed. Decided. Documented. Built to do it in under 5 seconds.

Fraud detection intelligence
In the build pipeline

31 archetypes. 6 categories. One engine that never blinks.

CATEGORY 01 · 7 ARCHETYPES

Billing Inflation

Upcoding, unbundling, and inflated procedure costs — caught by cross-referencing every line item against ICD / CPT norms and provider baselines.

UpcodingUnbundlingCost inflation
Claimed vs. expected cost+340%
Expected · EGP 1,200
Claimed · EGP 5,280
The member side
Designed · Coming next

Eligibility, pre-auth, and coverage — verified at the point of care

Members carry a biometric-secured digital health wallet. Every QR scan feeds the same fraud engine your operators trust — closing the identity-fraud loop before a claim is ever filed.

✓Face ID authentication ties every action to a verified member
✓Pre-auth QR cards validate coverage instantly at any provider
✓Real-time deductible tracking — no surprises at adjudication

Your health coverage. Always in your pocket.

9:41● ▂▄▆ ▮
IRONIC HEALTH
iRonic Health

Welcome back,
Mariam

Look at your phone to authenticate with Face ID and unlock your vitality portal.

Scan Face ID
Use passcode instead
Digital Health Wallet

Your cards

PRE‑AUTH QRMRI Scan
AUTH · LK‑77‑4410
MEMBER
Valid to 30 Jun
Deductible met0%
EGP 1,360 of 2,000 — EGP 640 remaining this year
RECENT
℞
e‑Prescription · Amoxicillin
Dr. Hassan · 2 days ago
▦
Pre‑auth QR · MRI Scan
Valid until 30 June
⌂ Home⇄ Journey◎ Care▭ Wallet○ Profile
One layer · Eight parties

Everyone in the claim, connected

Insurers

Interactive prototype

Carry the risk. Gain a real-time grip on loss ratio and fraud leakage.

TPAs

Interactive prototype

Adjudicate at scale with FRA-ready, AI-assisted decisions.

Hospitals

In the build pipeline

Submit and pre-authorize claims through one verified channel.

Pharmacies

In the build pipeline

e-Prescriptions validated against drug-splitting and volume anomalies.

Physicians

Designed · Coming next

Clinical justification and provider history scored on every claim.

Patients

In the build pipeline

Biometric identity and a digital wallet that closes the fraud loop.

Labs

In the build pipeline

Diagnostic claims cross-checked against orders and eligibility.

Imaging Centers

In the build pipeline

High-cost scans verified against authorization and duplicate flags.

Always scanning · demo simulation
Interactive prototype

Every claim, swept against 31 archetypes in real time

The engine never stops. As claims flow in from across the ecosystem, suspicious patterns light up the moment they're detected — scored, categorized, and routed before a single EGP leaves your portfolio.

4.3s
avg. decision time (demo)
2,847
claims swept (simulation)
23
fraud cases flagged (simulation)
Real‑Time Claims Analysis·Fraud Detection·Pre‑Authorization·Auto‑Adjudication·FRA Audit Trail·Loss Ratio Reduction·31 Fraud Archetypes·8 Ecosystem Parties·5‑Second Decisions·MENA Health Insurance Intelligence·
Built for the compliance era
Designed · Coming next

Decision support insurers and regulators can stand behind

FRA‑ALIGNED · PDPL 151/2020

Designed around Egypt's Financial Regulatory Authority requirements

Every decision is logged in a tamper-evident audit trail. AI outputs are decision support — never autonomous payment — keeping CMO and regulator control intact.

Tamper-evident audit trail
Every AI decision, fully traceable
PDPL 151/2020 data privacy
Encrypted in transit and at rest
CMO review controls
Human-in-the-loop on every flag
ICD / CPT code matching
Clinically grounded scoring
BUILT TO CONNECT EGYPT'S HEALTH INSURANCE ECOSYSTEM
Insurers FRA-licensed TPAs Hospitals Pharmacies Labs & Imaging Physicians

The fraud your current system is missing is compounding every day.
Let's show you exactly where it's happening.

A 30-minute live demo on a Provider Claims-style pilot scenario — see your own loss-ratio exposure modeled in real time.

Book a Live Demo →