The backbone
of modern healthcare payments.
ACCURACY WITHIN $0.10
Benchmarked against 500,000 historical Part B claims. Matched to actual 835 remittance within $0.10 per claim.
FULL PHASE 0–7 LATENCY
Your legacy system takes 14–30 days. CAPE processes the same claim in fifty milliseconds. That gap is the entire value proposition.
CFR RULES ENCODED
Every rule in the CMS Physician Fee Schedule encoded as executable math. Not approximated. Updated quarterly to reflect CMS PFS Final Rules.
Benchmarked against every major payer and regulator
// THE STATUS QUO
The infrastructure running US healthcare payments was built in the Clinton era.
Ancient architecture
TriZetto Facets. QNXT. Still adjudicating half a trillion dollars annually. Every implementation costs $10–50M and takes 18 months. No API. No audit trail.
LAST MAJOR UPDATE: ~1997 · NO API · NO AUDIT TRAIL
API-first engine
Built from the ground up for modern fintech infrastructure. Zero legacy dependencies. A fully documented REST API that integrates in days, not months.
CAPE v2.1.0 · CLOUD-NATIVE · WEBHOOK READY
30–60 day AR cycle
Submit a claim. Wait. PE firms close acquisitions without knowing what the practice actually collects. MA plans audit without a ground truth. The window is the problem.
AVG AR CYCLE: 30–60 DAYS · SOURCE: CMS CERT
50ms processing cycle
Send an 837P. Receive a complete CAPEDecision object — billed, allowed, payment, citations — before you submit the claim. The window closes to nothing.
PH.0–7 COMPLETE · ZERO APPROXIMATION
Black boxes. Zero citations.
Cotiviti. Optum. They return a payment amount. Ask which rule triggered it — silence. Ask for the CFR section — nothing. CARC codes with no derivation.
CARC 45 ≠ 42 CFR §414.22(b)(5)
Full citations & audit trails
Every calculation is mathematically tied to the raw Code of Federal Regulations. We return the exact rule ID and CFR section. Defensible in any Medicare audit.
RULE_ID: MED-P5-RVU · GPCI: FL-09
The infrastructure is broken. The math isn’t. Introducing CAPE.
// THE CAPE ENGINE
Adjudicate your claims instantly. For the first time.
Submit an 837P. Receive a complete CAPE decision in 50ms — billed, allowed, payment, every CFR citation. Before you submit. Before your AR cycle begins. Before the black box takes over.
Phase 0
Claim Intake
ASC X12 837P v5010 segment parsing — full loop identification and structural validation.
ASC X12 837P v5010
12 RULES IMPLEMENTED
Phase 1
Provider Validation
MAC jurisdiction lookup, fee schedule locality, and facility vs. non-facility PE GPCI routing.
42 CFR §414.20
28 RULES IMPLEMENTED
Phase 2
Eligibility Check
Part B enrollment snapshot, MSP detection, and QMB flag propagation for cost-share waiver.
42 CFR §411.20
22 RULES IMPLEMENTED
Phase 3
Medical Necessity
LCD/NCD coverage determination waterfall — ICD-10 validation against active policy maps.
42 CFR §405.500
45 RULES IMPLEMENTED
Phase 4
Coding Edits
NCCI PTP bundling edits, MUE unit limits, and global surgery period lookback validation.
CMS NCCI Policy Manual Ch. 1
38 RULES IMPLEMENTED
Phase 5
Pricing Systems
MPFS RVU calculation with GPCI locality factors — work, practice expense, and malpractice components.
42 CFR §414.22
51 RULES IMPLEMENTED
Phase 6
Modifier Adjudication
Bilateral surgery factor, MPPR reduction indicators, and mid-level provider adjustments applied.
42 CFR §414.22(b)(5)
31 RULES IMPLEMENTED
Phase 7
Financial Split
Deductible allocation, sequestration reduction, and HPSA bonus — final payment determination.
42 CFR §409.102
20 RULES IMPLEMENTED
// WHO WE SERVE
One engine.
Every reimbursement workflow.
Private Equity & Factoring
Run mathematical Quality of Earnings (QoE) audits. Uncover hidden EBITDA before acquisition. Package risk-free receivables for asset-backed finance.
MA Plans & TPAs
Stop overpaying. Audit paid claims data against the true CMS policy book. Uncover millions in phase 5 and phase 6 miscalculations.
Providers & Clearinghouses
Hit the CAPE API. Pre-adjudicate claims before submission. Eliminate denials and delete your 30-day AR cycle.
// WORK WITH US
Price claims to the cent.
Before you submit.
White-glove onboarding for enterprise healthcare finance teams.