This methodological study describes a payer-side audit pipeline for SOAT (Colombia's mandatory traffic accident insurance) claims and the related ADRES reimbursement workflows. Built from technical documentation, Colombian regulatory sources and recent literature, it applies six versioned audit instruments to each claim file: support validation, data structuring, cross-document consistency, clinical audit, atypicality detection and final ruling, organized as three sequential documentary phases, two parallel substantive phases and one consolidation phase.
The instruments contain 135 versioned audit elements, and two early-exit gates send a case straight to the final ruling when incomplete documentation or blocking inconsistencies make clinical audit inappropriate. A functional demonstration on 15 de-identified cases exercised all six decision rules and both gates, and financial reconciliation held across all 14 closed cases (COP 137.7 million billed), with source-level traceability and mandatory human review throughout. The work is a preprint not yet peer reviewed, and the authors note that prospective validation against expert auditors' decisions is still required.
