Use Case 1
Denial Triage & Appeal
Trigger: 835 remittance received
1.Parse denials by CARC/RARC codes
2.Classify root causes
3.Assess appeal merit against historical overturn rates
4.Draft appeal packages with evidence and policy citations
5.Route to biller for review and submission
6.Track appeal status to resolution
✓
Meritorious appeals get drafted in minutes, fought efficiently, and overturned at high rates.
Use Case 2
Closed-Loop Learning
Trigger: Appeal resolved (overturned or upheld)
1.Log outcome and root cause
2.Feed back into denial model
3.Update pre-submission risk scoring
4.Alert coding/operations on systemic issues
5.Adjust appeal strategy for future similar denials
✓
Every appeal makes the system smarter—denials drop, overturns rise.
Integrations
835 Remittance Processing
Practice Management / Billing System
Payer Portals (Availity, Change Healthcare)
Medical Policy Databases
Document Generation (appeal letters)
Industries
healthcare
See It In Action
A sample conversation with this agent
Process today's 835 remittance—what's denied and what should we appeal?
Processing 835. 84 denials across 12 root causes. Recommended for appeal: 41 denials totaling $87K — all have strong evidence and high historical overturn rates. Don't appeal: 28 denials where the payer is correct (duplicate submissions, truly non-covered services, timely filing violations). Borderline: 15 cases needing your judgment. I'll draft appeal packages for the 41 once you approve, with evidence, policy citations, and the payer's required format.
Draft the appeal for claim #7834—they denied our CHF admission as not medically necessary.
Drafting. Claim #7834, $14,200, denial reason CO-50. Building the appeal: (1) Cite medical necessity documentation from admission H&P (dyspnea at rest, BNP 1840, bilateral infiltrates on CXR). (2) Reference InterQual severity criteria met at admission. (3) Include discharge summary showing IV diuresis required and response to therapy. (4) Cite the payer's own CHF admission criteria from their published UM policy. Package is ready for biller review before sending.
What patterns are we seeing in denials that we can prevent upstream?
Top 3 patterns feeding back to the pre-submission agent: (1) 34% of current denials are documentation-specificity issues—same patterns our prospective HCC agent should catch. (2) 22% are auth-related, concentrated with Payer X's new referral policy. (3) 18% are timely-filing on claims stuck in biller work queues more than 60 days. Each of these has an upstream fix I'm recommending to operations.