AEGIS ISD is a healthcare program integrity platform for payment integrity, SIU, and medical review teams at commercial and Medicare Advantage health plans, Medicaid managed care plans, and state Medicaid agencies. It unifies fraud, waste, and abuse (FWA) detection, investigation, clinical review, and recovery in one workspace, so every decision sits in one audit-ready case record.
Detect screens pending claims before payment and recommends deny, suspend, review, or flag, while reviewers and the claims system keep the payment decision. After payment, detection runs scan paid and adjusted claims and route risk-scored alerts to analysts. One governed rule library serves both stages, with 100+ base rules, CMS NCCI and MUE edits, MS-DRG, and provider link analysis.
Case Management covers lead intake and triage, configurable case stages and approvals, allegations and claims, recovery and outcome tracking, dashboards, and scheduled reports.
Medical Review supports clinical and coding review with line-level decisions, QA verification, appeals, and statistically valid random sampling (SVRS): RAT-STATS-aligned sample sizing, seeded random selection, and Mean Per Unit extrapolation.
Provider Portal sends document requests to providers with one-time-passcode access, virus-scanned uploads, and automatic reminders. DataBridge loads and validates claims, provider, and member data. AEGIS AI gives evidence-linked answers in the context of the active case or alert, with a five-level trust model from Off to Autonomous. Drive keeps document evidence connected to every record.
Workflows, queues, scoring rules, and approval paths are configurable by line of business without custom code, and each customer's data is isolated in its own database schema. The platform holds SOC 2 Type II, ISO/IEC 27001, HIPAA, and CSA STAR Level 1.
Who Is the Company Behind AEGIS ISD?
