Coverage & Claim Readiness

Synthetic data · Stored example outputs · Simulated processing

Explore the workflow

Upstream intercept that catches eligibility, demographic, and authorization issues before a claim ships. A risk predictor ranks likely denial reasons per encounter. An eligibility interpreter parses X12 271 responses with flagged issues. A QA classifier surfaces field-level problems with severity and suggested fix.

• AI eligibility interpreter: parses X12 271 responses and returns a structured coverage interpretation with per-field confidence and a narrative summary
• AI risk predictor: ranks the top 5 likely denial risks for a scheduled encounter with confidence, reasoning, and recommended action
• AI claim QA classifier: scans a near-submission claim payload and flags fields with severity, suggested fix, and confidence
• Encounter workbench tying eligibility, scheduled service, and provider context into one inspectable record
• Risk pattern library of 12 named denial-prevention patterns (auth-required-no-auth, eligibility-stale, demographic-mismatch, payer-id-stale, modifier-required-missing, place-of-service-wrong, dx-procedure-inconsistent, timely-filing-window-tight, coverage-terminated, secondary-cob-needed, prior-auth-step-therapy, plan-year-reset-imminent) linked back to taxonomy nodes in the denial spine