AI Agentic Claims Optimization System
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation.
Problem Statement
The challenge addressed
Solution Architecture
AI orchestration approach
Illustrative preview (sample data, not verified outcomes): Mission Configuration Interface - Setup claims optimization mission parameters with batch claim selection and priority settings
Illustrative preview (sample data, not verified outcomes): Mission Execution Dashboard - Real-time monitoring of 11-phase workflow with system metrics, agent pipeline visualization, and execution logs
Illustrative preview (sample data, not verified outcomes): Tool Invocation Timeline - Detailed agent activity tracking showing tool calls, database queries, API invocations, and processing timestamps
Illustrative preview (sample data, not verified outcomes): Mission Results Summary - Completed optimization analysis with agent execution performance metrics and confidence scores
AI Agents
Specialized autonomous agents working in coordination
Mission Orchestrator Agent
Complex claim optimization requires coordinating multiple agents, managing workflow execution, and handling inter-agent communication across mission phases.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Coordinates all agents through mission phases, manages workflow execution with error recovery, allocates resources dynamically, handles agent communication routing, and synthesizes outputs from all agents into mission results with comprehensive audit trails.
Clinical NLP Agent
Clinical documentation contains unstructured medical narratives that must be accurately parsed to identify diagnoses, procedures, and supporting evidence for coding.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Extracts medical entities using advanced NLP models, performs medical named entity recognition (NER), identifies procedures and diagnoses from clinical notes, maps extracted entities to standardized codes, and uses vector search for context retrieval.
Coding Optimizer Agent
Suboptimal coding leads to underbilling, compliance risks, and missed revenue opportunities due to incorrect E/M levels, missing modifiers, or bundling issues.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Analyzes CPT codes against clinical documentation, optimizes E/M level assignment, recommends appropriate modifiers, detects improper bundling, suggests coding upgrades with revenue impact calculations, and provides evidence-based coding recommendations.
Payer Rules Agent
Each payer has unique billing requirements, LCD/NCD policies, and authorization rules that must be applied accurately to avoid denials.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Applies payer-specific billing policies using rule engine tools, validates LCD/NCD coverage requirements, checks prior authorization rules, monitors timely filing deadlines, and retrieves relevant payer policies from vector knowledge base.
Contract Analyzer Agent
Contracted rates vary by payer and service, and underpayments occur when charges don't align with negotiated fee schedules.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Validates charges against contracted fee schedules, detects underpayment opportunities, supports review of contract requirements, calculates expected reimbursement, and identifies rate optimization opportunities with revenue impact analysis.
Compliance Checker Agent
Healthcare billing must comply with HIPAA, OIG guidelines, and payer-specific regulations to avoid fraud allegations and compliance penalties.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Supports review of HIPAA requirements for all claim data, performs fraud detection using ML inference, validates OIG compliance requirements, checks documentation requirements, and applies regulatory guardrails with risk severity assessment.
Quality Assurance Agent
Before finalizing claim recommendations, all findings must be validated for accuracy, confidence calibration, and human escalation determination.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Performs final validation of all agent outputs, calibrates confidence scores across agents, determines human escalation requirements, formats output for downstream systems, and ensures recommendation quality meets thresholds.
Prior Authorization Agent
Prior authorization requirements are complex, vary by payer and procedure, and manual PA processes delay care and cause denials when not obtained.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Automatically detects PA requirements using payer-specific rules, submits authorization requests via payer portal APIs, tracks authorization status in real-time, supports CMS Gold Card optimization, and generates PA-related recommendations.
Denial Prediction Agent
Reactive denial management is costly; predicting denials before they occur enables proactive prevention and appeals preparation.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Uses ML models to calculate denial risk scores, classifies predicted denial reasons by category (medical necessity, coding, authorization, eligibility, timely filing), generates preventive actions, performs root cause analysis, and auto-generates appeal letters.
Real-Time Eligibility Agent
Eligibility-related denials occur when coverage is not verified before service or when benefit details are not accurately captured.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Performs real-time 270/271 eligibility transactions, retrieves complete benefit details including deductibles and out-of-pocket amounts, detects COB situations, validates network status, and integrates with FHIR endpoints for comprehensive eligibility data.
Patient Cost Estimator Agent
Price transparency regulations (No Surprises Act) require accurate Good Faith Estimates, and patients need clear cost information for financial planning.
Core Logic
Illustrative workflow design. Validate capabilities, performance, controls and integration requirements before implementation. Generates Good Faith Estimates compliant with No Surprises Act requirements, calculates patient out-of-pocket responsibility, applies deductible and coinsurance calculations, supports payment planning recommendations, and supports review of price transparency requirements.
Worker Overview
Technical specifications, architecture, and interface preview
System Overview
Technical documentation
Tech Stack
6 technologies
Architecture Diagram
System flow visualization