MF2 · Product module

Medical Fraud Filter

MF2 helps audit teams screen claims using configurable policy and guideline checks. Teams can align review logic with Centers for Medicare & Medicaid Services (CMS) guidance, payer policies, coding standards, and internal audit priorities — and apply it the same way to every claim.

Discuss Rule Set Configuration View full workflow
What it does

From raw claim volume to a prioritized review queue.

What MF2 screens

  • Claims against predefined and configurable rule sets
  • Alignment with Centers for Medicare & Medicaid Services (CMS) guidance
  • Payer policies and coding standards
  • Internal audit criteria specific to your program

What MF2 produces

  • Flags identifying claims for deeper review
  • Prioritized audit queues based on configured criteria
  • Explainable findings with links to supporting evidence
  • Exportable results for downstream review and reporting
Configuration

Your policies, encoded as checks.

MF2 does not impose one screening logic on every customer. Checks are built from the guideline sources your program already relies on, so screening reflects your policies — not a black box.

CMS guidance

Checks referencing applicable CMS guidance relevant to the claims you review.

Payer policies

Plan-specific coverage and reimbursement policies translated into screening logic.

Coding standards

Checks for coding consistency against the standards your reviewers already apply.

Internal audit criteria

Your team's own priorities and thresholds, encoded and applied consistently.

Configured with you, versioned over time. Rule sets are set up together with your team, documented, and version-controlled, so every flag can be traced to the checks in force when it was raised. References to CMS and other guideline sources describe configuration inputs — they are not endorsements or approvals.
Screening flow

Exceptions, flags & queue prioritization

The same checks apply to every claim, every time. Exceptions are flagged with a written rationale and linked evidence, so reviewers see why a claim surfaced — not just that it did.

Flags are starting points, not verdicts. MF2 identifies claims for deeper review — it does not label claims as fraudulent. Determinations remain with qualified human reviewers and your adjudication process.
  1. Claims screenedIncoming claims enter MF2 as PHI-minimized data prepared upstream.
  2. Checks appliedYour configured policy and guideline checks run consistently across the batch.
  3. Exceptions flaggedClaims that trigger a check are flagged with the rationale and evidence links.
  4. Queue prioritizedFlagged claims are ordered by your configured audit criteria.
  5. Reviewer assignedPrioritized claims route to the right reviewer for human-led adjudication.
Capabilities

Built for audit teams that answer to policy.

Every capability supports the same goal: consistent, explainable screening that reviewers and audit managers can stand behind.

Configurable rule sets

Start from predefined checks, then tune thresholds and criteria to match your audit program.

Policy-based checks

Screening logic grounded in CMS guidance, payer policies, coding standards, and internal criteria.

Claim prioritization

Audit queues ordered by configured criteria, so reviewer time goes where it matters most.

Evidence links

Each flag points to the claim elements and check logic that produced it, ready for validation.

Reviewer assignment

Route flagged claims to the right reviewer based on queue, workload, or specialty.

Exportable findings

Screening results formatted for downstream review, reporting, and audit documentation.

In the platform

MF2 sits between protection and deep review.

In the full ClaimClean workflow, MF2 receives PHI-minimized claim data from Anonymization Service and hands prioritized claims to Audit Insights Assist for record-level analysis and evidence-ready reporting.

See the full platform workflow

Bring consistency to claim screening.

Talk to us about encoding your policies, guidelines, and audit criteria as configurable checks — and the prioritized queues that follow from them.

Discuss Rule Set Configuration Read our trust approach