Autonomize Fraud-Waste and Abuse is an AI-powered healthcare claims review application that uses advanced AI Agents to detect Fraud, Waste, and Abuse in claims. It gives healthcare payers a dashboard to review claims flagged by AI workflows, covering claim audits, DRG coding validation, medical necessity checks, and readmission analysis. Each review type surfaces risk scores, AI reasoning, and financial exposure so analysts can prioritize and act on the highest-risk claims.
Built natively on the ServiceNow Healthcare & Life Sciences (HCLS) data model, the app extends sn_hcls_claim_header, sn_hcls_claim_line, sn_hcls_member_plan,sn_hcls_practitioner and sn_hcls_policy with FWA intelligence fields. Organizations already running ServiceNow HCLS can adopt the app without migrating data.
What it does
- Pre-payment claim review: AI flags upcoding, missing modifiers, unsupported diagnoses and eligibility gaps with evidence and policy citations.
- DRG clinical validation: CC/MCC verification, expected-vs-assigned DRG comparison, and financial variance calculation.
- Medical necessity review: four-criteria assessment with AI clinical rationale and recommended level of care.
- Readmission analysis: clinical relatedness, preventability and HRRP penalty risk for 30-day readmission pairs.
- Provider outlier detection: statistical detection rules with an executive dashboard and drill-down to individual claims.
- SIU case automation: AI-generated investigation packages with timeline, evidence, financial impact and recommended actions.
What's included
- FWA intelligence fields across 5 standard HCLS tables
- Custom tables for AI findings (claim_finding) and workflow audit (claim_execution)
- Review queues, executive KPI dashboard and claim viewer UI
- Role-based access control (user, claim submitter, claim reviewer, system, admin)
- Asynchronous REST integration framework for the external AI platform
- Idempotent provisioning scripts for automated deployment
Requirements & compatibility
- ServiceNow Healthcare & Life Sciences (HCLS) data model installed
- Zurich family release or later
- Outbound REST connectivity to the Autonomize Genesis AI platform (HTTPS)
- Single-tenant (not domain-separated / MSP). No Now Assist or AI Agent Studio dependency.
Autonomize Fraud-Waste Abuse is an AI-powered Fraud, Waste & Abuse detection
application for healthcare claims, built on the ServiceNow platform and
powered by Autonomize Genesis AI.
Key capabilities:
• Automated claim risk scoring using AI workflows
• DRG upcoding detection with financial variance analysis
• Medical necessity review against clinical documentation
• Readmission pattern analysis
• Outlier detection across provider billing patterns
• Payer intelligence for denial risk prediction
How it works:
1. Claims are submitted or imported into the FWA app
2. Reviewers click "Run Payer Intelligence" on any claim
3. Genesis AI workflows analyze the claim against clinical policies
4. Results (risk score, AI summary, findings) are written back to the claim
5. SIU investigators act on flagged claims
Prerequisites:
• Active Autonomize Genesis AI subscription (contact info@autonomize.ai)
• Genesis API key, org ID, project ID, and workflow IDs (provided by Autonomize)
• Configure credentials post-install via System Properties → Autonomize FWA Genesis Configuration
Roles included: Claim Submitter, Claim Reviewer, Clinical Reviewer, SIU Investigator, Admin
Demo data included (tagged demo_data) for evaluation purposes.
v1.0.5 — Initial store submission
• Complete FWA claim analysis suite with 6 AI workflow integrations
• Role-based access control (5 roles)
• Automated Genesis AI polling via scheduled job
• Demo data included for evaluation (tagged demo_data, removable post-install)
• Credentials ship as empty placeholders — configured post-install via System Properties
• ServiceNow instance running Yokohama or Zurich
• Admin-level access to configure system properties post-installation
• Active Autonomize Genesis AI subscription
(obtain API key, Org ID, Project ID, and Workflow IDs from info@autonomize.ai)
Other Requirements:
• Genesis AI credentials must be configured post-install before the app
can process claims. See Installation Document for setup steps.
• Demo data (16 claims, 12 providers, 12 members, 10 medical policies)
is included and tagged "demo_data" — removable after evaluation.