Alaffia Health
Agentic AI for health plan claims operations, and the only payer side vendor in this lane: the buyer is the plan rather than the provider. Covers the full claims lifecycle across payment integrity, utilization management, and appeals. Proprietary optical character recognition digitizes unstructured itemized bills and medical records, agents extract and structure clinical facts and cross reference a claim against the complete patient record, clinical criteria, and policy guidelines, automating routine cases and prioritizing high value claims for human review. A generative assistant helps reviewers summarize records, source guidelines, and draft determination responses. The company states it deliberately avoids black box denial algorithms: every recommendation carries a clinical rationale and traceable citations, and licensed clinicians validate and sign off. Maintains SOC 2 Type II, HIPAA, and HITRUST. Reports saving health plans more than $120 million, over 20 percent average savings on high cost facility claims, and go live in roughly 30 days. Founded 2020 by siblings TJ Ademiluyi and Adun Akanni; $55 million Series B in February 2026 led by Transformation Capital, bringing total funding above $73 million.
Capability Axes
Agents perform the review itself: OCR digitizes unstructured bills and records, models extract clinical facts and cross reference the claim against the full patient record and policy criteria. The human clinician validates a machine produced finding rather than conducting the review.
The most deliberate oversight position in the index, and it is a direct response to a live regulatory problem. The company states it avoids black box denial algorithms of the kind drawing regulatory backlash, grounds every insight in verifiable record data, attaches a clinical rationale and traceable citations to each recommendation, and keeps licensed clinicians at the point of validation and signoff. In claims denial, where an opaque model decision has direct patient consequence and growing legal exposure, designing for defensibility rather than throughput is the correct answer and it is stated explicitly.
Specific and falsifiable figures: more than $120 million in reported medical cost savings, over 20 percent average savings on high cost facility claims, return on investment above five times, review cycles compressed from weeks to days, and roughly 30 day implementation. Held back from A because the figures are vendor reported without published methodology or an independent audit, and savings attribution in payment integrity is notoriously difficult to isolate.
SOC 2 Type II, HIPAA, and HITRUST all stated, the appropriate certification set for a vendor handling payer claims and clinical records. Held back from A because no public trust center with control level detail or named audit dates was retrieved.
No public pricing. Contact the vendor. Sold to health plans as a cloud platform or fully managed service, with commercial terms typically tied to review volume and savings delivered rather than a list price. Buyers should establish whether pricing is contingent on identified savings, since that structure aligns incentives toward finding denials and warrants scrutiny of the clinician review checkpoint.
Precisely bounded and unusually honest about it: health plan claims operations across payment integrity, utilization management, and appeals. The company states it is not a browser automation tool or a general agent builder, and is specialized for the payer rather than applicable across healthcare.
Pricing
Vendor-published figures are labeled as such. Figures labeled “Estimated” are derived from third-party sources and have not been confirmed by the vendor.
| Entry Price | Pricing Basis | BAA Tier | Implementation | Source |
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Contact the vendor
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Enterprise engagement tied to review volume and savings delivered | — | — | Vendor Published |
No rate card published. Sold to health plans as a cloud platform or fully managed service, with terms typically tied to review volume and savings delivered rather than a list price. The structure is worth scrutiny in procurement: if compensation is contingent on identified savings, the incentive runs toward finding more denials, which makes the clinician validation checkpoint the control that matters.