Hospital RCM teams
High-volume denial queues triaged by root cause so staff work recoverable cases first.
Revenue Cycle · AI Agent
Claims Denial Management & Appeals Agent
The agent flags claims likely to deny before they go out, reads the CARC/RARC reason codes on every remittance, and drafts the appeal — so billers approve well-built appeals instead of rebuilding them.
Human-in-the-loopHIPAA-ReadyAudit LoggedX12 835/837
Trusted by global innovators
Denials are a re-work tax on the revenue cycle
A large share of denied claims are never reworked, and the rest cost staff hours each — reading the remittance, decoding CARC and RARC codes, pulling documentation, and typing an appeal payer by payer — while the same avoidable errors keep going out the door. The agent works both ends: before a claim is sent it scores denial risk from coding, payer, and history; after a denial posts it parses the X12 835 remittance, classifies the CARC/RARC reason, and drafts a cited appeal letter. A biller reviews and sends every appeal — the agent never files on its own.
Predict, decode, appeal — one pipeline
Reference architecture for how this agent connects to your EHR and data systems.
Key Capabilities
Denial prediction and auto-appeals grounded in the remittance — CARC, RARC, and the 835.
Pre-submission denial prediction
Scores each 837 claim's denial risk from coding, payer, and historical patterns before it is sent.
CARC/RARC code analysis
Parses the X12 835 remittance and classifies each denial by its Claim Adjustment Reason Code and Remittance Advice Remark Code into a groupable root cause.
Auto-drafted appeal letters
Generates a payer- and reason-specific appeal letter with the evidence that rebuts the denial — drafted for review, never auto-filed.
Appealability triage
Separates denials worth appealing from write-offs and corrections, routing each to the right queue.
Who runs it
Deployment scenarios
The same agent, pointed at the denials that cost you the most.
Physician groups
Coding-driven denials caught pre-submission and appealed with practice-specific templates.
Billing companies
One agent across many clients, each with its own payer rules and appeal libraries.
Specialty practices
Medical-necessity and modifier denials common to oncology, cardiology, and orthopedics.
Expected impact once the agent is live
Directional impact, validated per deployment rather than guaranteed.
Pre-submit
Denial risk flagged before the claim goes out
Drafted
Appeals written for review instead of from scratch
1 gate
Biller sign-off before every appeal is filed
Compliance-First Healthcare App Development Services Backed by Global Standards
15-Minute Scoping Call01
HIPAA
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, strict access controls, and traceable audit logs.
02
GDPR
General Data Protection Regulation
Implement lawful consent flows, data minimization, retention controls, and secure processing for sensitive health data.
03
FHIR
Fast Healthcare Interoperability Resources
Enable standardized health data exchange across apps, care teams, and systems through robust FHIR-ready APIs.
04
HL7
Health Level Seven International
Support enterprise-grade interoperability with HL7-based integrations for records, events, and clinical messaging workflows.
05
HITRUST
Health Information Trust Alliance
Align security programs to healthcare-specific control and risk management practices trusted by providers and ecosystem partners.
06
HITECH
Health Information Technology for Economic and Clinical Health Act
Design with breach notification readiness, digital record safeguards, and operational controls that support regulated care programs.
07
SaMD
FDA Software as a Medical Device
Plan software quality, traceability, and documentation pathways for products that may require SaMD review and submission.
08
MDR (EU)
Medical Device Regulation (European Union)
Prepare EU market-ready processes for risk classification, evidence tracking, and lifecycle governance under MDR expectations.
09
SAMHSA
Substance Abuse and Mental Health Services Administration
Apply confidentiality controls and consent-aware sharing models for behavioral and mental health data experiences.
Standards it speaks
Transactions and controls
X12 835X12 837CARC/RARCFHIR R4HIPAASOC 2
How It Works
Predict → decode → draft → submit
A four-stage pipeline that catches denials before they happen and turns the rest into reviewed appeals.
1.
Capture the claim & remit
The agent ingests outgoing 837 claims and incoming 835 remittances, linking each denial to its claim and EHR clinical context over FHIR.
835 / 837 intake
2.
Predict & classify
Pre-submission it scores denial risk; post-denial it decodes CARC/RARC into a root cause and judges appealability — flagging uncertainty.
Model + rules
3.
Draft & human review
It drafts the appeal with cited evidence and routes it to a biller, who approves, edits, or rejects. No appeal is filed without a human action.
Sign-off required
4.
Submit & write back
The approved appeal or corrected claim is submitted, and the outcome, reason code, and status are written back for tracking and analytics.
System write-back
Related proof of compliant AI delivery
Read Case StudyLera Health: compliant women's health platform
Related delivery proof from our compliant, AI-assisted healthcare work — not this exact agent.
Compliance & Guardrails
15-Minute Scoping CallGuardrails on every appeal
In healthcare, the guardrails matter as much as the capability.
PHI handling
Claim, remittance, and clinical data stay in HIPAA-ready, encrypted infrastructure under a BAA, minimum-necessary per appeal.
Human-in-the-loop
Every appeal and correction is reviewed and sent by a biller; the agent drafts and classifies, never files on its own.
Explainability
Each appeal names the CARC/RARC code it answers and cites the evidence used to rebut it.
Audit logging
Every prediction, classification, draft, edit, approval, and submission is timestamped and attributed.
Frequently Asked Questions
Yes. Claim, remittance, and clinical data stay in HIPAA-ready, encrypted infrastructure under a signed BAA, with minimum-necessary evidence per appeal and full audit logging.
Ready to shrink your denial backlog?
Tell us your workflow and systems, and we'll return an architecture review and a phased rollout plan.
contact@agnotic.com
Partnerships
contact@agnotic.com