Medical Claims Adjudication Agent
Reviews, scrubs, and adjudicates medical claims against payer rules before submission to reduce healthcare claim rejections and speed reimbursement.
Billing teams at medical practices and hospitals manually cross-check every claim line against CPT/ICD-10 coding rules, payer-specific edits, and prior authorization requirements before submission, a process that consumes hours per batch and still lets errors slip through, driving denial rates up and delaying cash flow
Staff must re-key data between the practice management system and clearinghouse portals, track down missing modifiers, and manually flag mismatched diagnosis-procedure pairs
This agent ingests raw claim batches, applies payer-specific edit logic and medical necessity checks automatically, and flags exceptions before they leave the building
It cross-references patient eligibility, coordination-of-benefits data, and historical denial patterns to predict which claims are most likely to be rejected
The agent pulls claim batches from the practice management or billing system via API, normalizes claim fields, and runs them through a rules engine encoding payer-specific medical billing edits, NCCI code pairs, and modifier logic. It cross-references patient eligibility and prior authorization status pulled from payer connections, scores each claim for denial risk using historical adjudication outcomes, and routes flagged claims to a billing specialist queue with the specific defect highlighted. Clean claims are automatically packaged and transmitted to the clearinghouse in the required X12 837 format, with confirmation receipts logged back to the source system.
Ingest Claim Batch
- Pull pending claims from practice management system
- Normalize CPT, ICD-10, and modifier fields
- Match claims to patient encounter records
Apply Payer Edit Rules
- Run claims through payer-specific medical necessity and NCCI edits
- Check coordination-of-benefits and eligibility status
- Score denial risk using historical claim outcomes
Route Exceptions for Review
- Flag claims missing modifiers, authorizations, or coding mismatches
- Assign flagged claims to billing specialists with defect notes
- Track resolution turnaround per specialist
Submit and Reconcile
- Package clean claims into X12 837 format
- Transmit to clearinghouse and log confirmation numbers
- Reconcile submission status against payer acknowledgments