Otera + Majesco ClaimVantage

Overview

Majesco ClaimVantage stores claim data, manages workflows, and enforces business rules for life, accident, and health insurers. The platform tracks each claim through adjudication, but examiners still review documentation and determine benefit decisions. When Otera connects to Majesco, autonomous AI agents handle that decision layer and execute benefit determinations, enabling end-to-end adjudication from intake through payment.

How It Works

Otera works alongside Majesco ClaimVantage, extending claims administration into autonomous, end-to-end adjudication.

• Receive claim data: Agents pull policy details, documentation, and workflow triggers from ClaimVantage, assembling the information needed for benefit determination.
• Evaluate eligibility: Otera determines benefit eligibility with specialized AI agents that enforce policy terms against medical findings and claim circumstances, handling the complexity that makes adjudication time-consuming.
• Process claims: Agents return adjudication decisions to ClaimVantage, calculating payment amounts and triggering disbursement workflows to move claims toward settlement.
• Escalate complex cases: When medical documentation is ambiguous or benefit calculation requires examiner judgment, Otera raises the claim with a clear summary of the decision points involved.