Use Case 1
Pre-Visit Eligibility & Cost Estimate
Trigger: Scheduled patient within 48 hours of visit
1.Run 270/271 against primary payer and detect BH carve-out routing
2.Cascade through carve-out vendor (Magellan, Optum BH, Carelon)
3.Extract BH-specific benefits: copay, visit limits, PA trigger thresholds, deductible status
4.Calculate patient out-of-pocket at contracted rate
5.Draft patient-facing cost summary in preferred language
6.Route for front-desk approval before sending
✓
Patients know their costs before the visit; staff handle only exceptions.
Use Case 2
Parity-Aware Claim Submission
Trigger: Encounter closed and ready for billing
1.Generate claim from session note with correct CPT, modifier, POS
2.Pre-validate against payer-specific edit rules and historical denial patterns
3.Flag NQTL/parity anomalies (BH-only session caps, fail-first protocols, stringent PA triggers) for biller review
4.Submit clean claims via EDI 837; route flagged claims to biller queue with pre-drafted parity arguments
5.Track adjudication via daily 835 polling
✓
BH-specific denial patterns get caught upstream; parity arguments built in from day one.
Use Case 3
Denial Triage & Appeal
Trigger: 835 remittance received
1.Classify denials by CARC/RARC and root cause
2.Distinguish meritorious appeals from correctly-denied claims
3.Draft appeal packages with clinical evidence and MHPAEA parity arguments where applicable
4.Route to biller for review and submission
5.Track resolution and feed outcomes back into pre-submission model
✓
Appeals get drafted in minutes, fought efficiently, and overturn at high rates—every appeal makes the next claim cleaner.
Integrations
270/271 Eligibility (X12)
BH Carve-Out Vendor APIs (Magellan, Optum BH, Carelon)
FHIR R4 / CMS-0057 PA Submission
EDI 837 / 835 Processing
Practice Management / EHR (Epic, athenahealth, TheraNest, SimplePractice)
Patient Messaging (multilingual)
Approval Workflow (AskUserQuestion)
Industries
healthcare
See It In Action
A sample conversation with this agent
New patient Maria Santos has her intake tomorrow—run the full pre-visit RCM pipeline.
Step 1 eligibility: 270 to Aetna (medical), 271 returns BH carve-out to Optum (payer ID 87726). Cascade triggered—running 270 against Optum BH. She has 26 BH outpatient visits remaining this plan year, $40 copay, deductible met. Step 2 PA requirement: 90791 intake doesn't require PA, but 90837 (60-min therapy) does after visit 8 with this carve-out. Logging the trigger. Step 3 cost estimate: $40 today, drafting patient-facing summary in Spanish per her language preference. Holding for front-desk approval before send.
Why is claim #BH-4421 flagged for parity review before I submit?
Two things: (1) the visit was 60-minute psychotherapy coded 90837 with the patient at the 12th session, but the payer's UM applied a session cap that doesn't apply to comparable medical/surgical services in the same classification—that's an NQTL parity flag I capture pre-submission. (2) the denial pattern model shows a 34% historical denial rate when this payer sees 90837 past session 10 without PA, even though their published policy says PA isn't required until session 15. I'm not going to silently submit and let it deny. Routing to your biller with the parity argument pre-drafted and the suggested approach: submit with a PA-on-file note referencing the payer's own policy. If denied, the parity argument carries the appeal.
835 came back—what's the play on today's denials?
47 denials totaling $18.2K. Triage: 22 are CO-50 medical necessity—15 have strong clinical documentation and high overturn-rate patterns, drafting appeals now; 7 are correctly denied (services after benefit exhaustion). 14 are CO-197 PA-related—12 are the carve-out vendor saying 'no PA on file' when our records show otherwise; pulling auth numbers from our PA tracking and resubmitting. 11 are smaller misc. The 22 medical-necessity appeals package the clinical narrative plus MHPAEA parity arguments where the denial pattern shows BH-only stringency. None go out without your biller's sign-off.