Faster claim review
Lower revenue leakage
Fewer denials before they happen
Full packet review
Reads UB-04, CMS-1500, ED notes, operative notes, imaging reports, anesthesia records, pathology reports, and pharmacy records together.
What Is It?
A claim validator that reads the full packet, not just the form
Our Agentic RCM Claim Validator helps healthcare billing and coding teams reduce denials before submission by reviewing the complete claim packet — not just the claim form. It connects every billed line item with supporting clinical evidence, validates coding and payer logic, and gives teams a clear view of what is supported, what is missing, and what needs review. The result is faster claim review, fewer avoidable denials, stronger documentation confidence, and lower revenue leakage.
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From claim packet to validated output
Ingest the claim packet
UB-04, CMS-1500, EDI files, clinical notes, imaging reports, operative notes, anesthesia records, pathology, and pharmacy data.
Extract key information
Patient details, provider details, diagnosis codes, procedure codes, dates of service, billed line items, and supporting evidence.
Validate against rules and APIs
NPI, ICD-10-CM, NCCI, DRG/IPPS, and payer-specific logic checked against each billed line.
Score denial risk
Each claim line is marked Eligible, Review, or Not Eligible based on evidence coverage and rule validation.
Generate an action-ready report
Billing teams see what is supported, what is missing, and what should be corrected before submission.
Evidence-backed validation
Maps every charge to its proof and combines AI reasoning with deterministic checks — NPI validation, ICD-10-CM lookup, DRG/IPPS logic, and NCCI edit logic.
Clear, actionable output
Every line is labeled Eligible, Review, or Not Eligible — with the reason cited, so billing teams know exactly what to act on and what proof is missing.
Grounded in trusted healthcare validation logic
NPI / NPPES
Verifies provider identity and NPI details against the national provider registry.
ICD-10-CM lookup
Confirms diagnosis codes are valid, active, and correctly described for the claim.
NCCI edits
Checks whether two procedures should be billed together or may need modifier review.
DRG / IPPS logic
Reviews inpatient claim logic under Medicare-style grouping rules.
Payer-specific rules
Applies Commercial and Medicare logic views to identify how denial risk differs by payer.
Same team. Fewer denials. Less manual effort.
Your process today
Each claim reviewed manually across disconnected systems.
High-risk lines reviewed by eye with limited context.
Deviations flagged, but coding citations take time to locate.
Limited visibility into why a claim line is at risk.
With our Agentic RCM Claim Validator
Full claim packet reviewed — every line linked to clinical proof.
Denial risk surfaced automatically before submission.
Every finding cited to the exact coding rule or payer logic.
Structured report shows what is supported, missing, or at risk.
Turn claim review into a revenue protection engine
Built for healthcare billing, coding, and revenue cycle teams — the solution reviews the full claim packet, links charges to clinical proof, checks coding logic, and highlights denial risks before they become lost revenue. This also includes migrating codes from ICD-10-CM to ICD-11, along with an agentic chatbot that lets users ask questions about the data in simple language. The chatbot analyzes the available data, map with ICD codes and provide predictive insights to support better decision-making.
30–45%
Reduction in initial denials
+5–8 pts
improvement in clean claim rate
8–15 days
fewer A/R days
50–70%
faster pre-bill review
15–25%
lower cost-to-collect
For a provider processing 100,000 claims per year at an average net reimbursement of $900 per claim —even a 3–4% improvement in avoidable denial prevention protects $2.7M–$3.6M in annual revenue exposure— before savings from lower rework, faster collections, and reduced appeal effort.
Ask anything about the claim — once the validation is done
Once the validation pipeline completes, an agentic chatbot becomes available — automatically context-aware. It has already processed the claim's extracted data, validation outcomes, and audit findings before the first interaction. Your team can query it in plain language without rebuilding context from scratch.
Explain any flagged line
Ask why a specific line item was denied or flagged — get the evidence, the rule it failed, and the recommended fix in one response.
Differential diagnosis from claim data
Generate potential diagnoses with ICD-11 codes and probability estimates, derived directly from the clinical documentation in the claim packet.
ICD-10 to ICD-11 mapping
Cross-reference billed ICD-10 codes against ICD-11 equivalents via the WHO API — with definitions, hierarchy, synonyms, and exclusions on demand.
Live ICD-11 lookup
Look up any ICD-11 code in full detail — including WHO browser references — without leaving the validation environment.
Live example — from the actual validation run on CLM-MBR3105
Screenshot shows a live chatbot query: "Check ICD codes and mapping and give me a list of other potential diseases with their probability and how do you achieve the results." — with real-time WHO ICD-11 API lookups and a full differential diagnosis table for patient Noah Bennett (CLM-MBR3105).
More than a claim scrubber
Capability | Legacy claim scrubbers | Agentic RCM Claim Validator |
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Payer logic | Often payer-agnostic | Supports Commercial vs Medicare logic views |
Validation approach | Mostly rule-based | Combines agents, document intelligence, and deterministic APIs |
Denial context | Flags issues, limited context | Links each billed line to proof documents |
What it reviews | Checks fields and codes | Reads the full claim packet |
Frequently Asked Questions
Validate claims before they become denials
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Share a sample of your claims
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We run a live validation
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You see the denial risk report
Share a sample from your claims pipeline. We'll run it through our Agentic RCM Claim Validator and show you exactly what your team is currently missing before submission.