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Documentation Index

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Category: Revenue Cycle & Operations  ·  Signals: Claim line items · Payer edit rules · Modifier logic · NCCI edits
Catch claim errors before they leave the practice.

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Overview

The Claims Review Agent scrubs every claim against payer edit rules and NCCI edits before submission, surfacing errors with fix suggestions and routing clean claims to billing. Every edit failure carries a rationale and a suggested fix.

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How this agent works

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Configuration

This agent takes the following configuration from your practice settings:
  • Payer edit rule library
  • NCCI edit set
  • Modifier policy
  • Pre-submission approval workflow

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Execution

At runtime, the agent executes the following steps:
  1. Reads the claim before submission
  2. Runs payer edit rules and NCCI edits
  3. Validates modifier and code-pair logic
  4. Surfaces errors with rationale and fix suggestions
  5. Routes to billing for approval and submission

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Composable experts

The Claims Review Agent bundles the following experts from the registry:
ExpertRole
Payer Edit Rule ExpertCarrier-specific edits
NCCI Edit ExpertNational Correct Coding Initiative
Modifier ExpertModifier logic and validation
Claim Structure ExpertLine item and total validation

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Typical use cases

  • Catch edit failures before submission, not after denial
  • Validate modifier logic on every claim
  • Surface errors with fix suggestions, not just rejections
  • Reduce denial rate without retraining billing staff

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Compliance & safety guarantees

  • Every edit failure is reported with a rationale
  • Fix suggestions are surfaced, not auto-applied
  • Submission requires explicit billing approval

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Tags

Claims · Scrubbing · NCCI · Modifiers

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