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Claims Management

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Overview​

The Claims Management Agent automatically assembles, optimizes, and submits claims with fewer denials. It automates selected portions of your claims life cycle—assembling, validating, scrubbing, optimizing, and submitting claims—while ensuring every field and code is complete and compliant with payer rules and contracts. By combining claim-scrubbing, compliance checks, and insights from past denials, it reduces common errors, improves first-pass acceptance rates, and speeds up reimbursements. This unified approach cuts down on manual work, minimizes rejections, and streamlines communication with payers.

Capabilities​

  • Claim submission and tracking
  • Missing information detection (patient, provider, codes)
  • Coding verification & optimization (ICD-10, CPT, HCPCS)
  • Policy & contract compliance checks
  • Adaptive learning from denial patterns

Key Benefits​

  • Higher First-Pass Acceptance - Scrubs data for missing or incorrect fields, invalid member IDs, and coding mismatches; flags issues before submission.
  • Prevent Denials & Disputes - Cross-references claims against policy and contract libraries to detect excluded services or insufficient documentation, preventing costly rejections and appeals.
  • Adaptive Learning - Continually refines logic based on historical claim outcomes, recognizing payer-specific patterns that lead to rejections or denials.
  • Timely Filing Management - Tracks filing deadlines, automatically prioritizing urgent claims, and preventing late submissions.
  • Multi-Payer Coordination - Simplifies handling of primary, secondary, and tertiary claims, ensuring correct routing and coverage calculations.
  • Time & Resource Savings - Automates key checks and leverages a single solution for coding validations, policy compliance, and claims submission, minimizing manual reviews.

Inputs​

  • Encounter/visit data - e.g. EDI 837—professional or institutional
  • Coding details, billing rules, and policy/contract documents - could be PDF, Word, HTML, etc.
  • Past denial data - CSV, JSON and explanations of benefits (EOBs)
  • Provider–payer contractual agreements and regulatory references

Outputs​

  • Validated or Corrected Claims - Updated claims with missing fields filled, invalid codes corrected, or compliance gaps resolved.
  • Compliance & Coding Recommendations - Summarizes policy adherence checks, highlights conflicts, and suggests fixes with references to specific payer policies.
  • Claim Status Updates - Accepted, rejected, or pending—plus error feedback or recommended corrections.
  • Optional Text Summary or Annotated Claim File - Quick staff review indicating what was modified or flagged for each claim.