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AI agent for medical billers

Claim Denial Rework Agent

Recover denied claims before filing deadlines

AdministrationAutomationHealthcare
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Claim Denial Rework Agent: what goes in, what the agent does and what you get

What it does

Denied claims are lost money unless someone reads the reason, fixes the cause and resubmits in time. When a remittance file arrives, this agent reads each denial, groups denials by reason code and ranks them by amount and days left to appeal. Claims within 15 days of the deadline go first. It pulls chart and authorization data and works out the likely fix: a missing modifier, an authorization number, a diagnosis that does not support the service or a visit limit. It drafts the corrected claim or appeal and checks it against the payer's edits. Claims that cannot be fixed from the record go to the provider with a question. A biller or provider approves every resubmission. It then watches for payment and moves to the next appeal level if denied again. Write-offs need a person's decision. Edge case: a timely filing denial is checked against proof of first submission.

How it works

Follow the arrows from top to bottom. The orange dashed arrow is the loop: when a check fails, the agent goes back and tries again.

Start and resultWhat it doesA check on its own workWaits for your OKGoes back and retries
Yes, continueApprovedYes, continueNoNo 1 STARTS WHEN Remittance file arrives 2 USES A TOOL Read denials and group by reason code 3 DOES Rank by amount and days left to appeal 4 USES A TOOL Pull chart and authorization data for each claim 5 DOES Draft corrected claim or appeal 6 CHECKS THE RESULT Does the corrected claim pass payer edits? If not: ask the provider for the missing documentationand redraft. Back to step 4. 7 YOU APPROVE Biller or provider approves resubmission 8 CHECKS THE RESULT Was the claim paid? If not: move to the next appeal level or write-offreview. Back to step 5. 9 RESULT Denial log with recovered amounts
Read the steps as a list
  1. Remittance file arrives
  2. Read denials and group by reason code
  3. Rank by amount and days left to appeal
  4. Pull chart and authorization data for each claim
  5. Draft corrected claim or appeal
  6. Does the corrected claim pass payer edits?If not: ask the provider for the missing documentation and redraft. Back to step 4.
  7. Biller or provider approves resubmissionThe agent waits here for your OK.
  8. Was the claim paid?If not: move to the next appeal level or write-off review. Back to step 5.
  9. Denial log with recovered amounts

How it decides

Denials are ranked by amount and days left to appeal. Each reason code maps to a fix, and the fix must pass payer edits before resubmission.

  • Claims within 15 days of the deadline go first
  • Write-offs require a person's decision
  • Patterns of the same denial get a root-cause note

Make it yours

Every agent is a starting point. You choose these settings for your own situation.

  • Days-to-deadline threshold
  • Payers in scope
  • Who approves resubmissions
  • Write-off amount limit for review

What keeps you in control

It always asks you first

  • Every resubmission and appeal
  • Any write-off

Hard limits

  • Never change a code without documentation support
  • Never bill for undocumented services

It stops when

  • Done: claim paid or written off with approval
  • Stop: final appeal level reached

Set it up

We guide you through the set-up, step by step

Members get the full set-up guide for this agent. No technical skills needed: you copy, paste and upload.

10 minto set it up in your AI
5 AIsChatGPT, Claude, Copilot, Gemini, Grok
  • One set of instructions to paste into your AI, with the clicks for ChatGPT, Claude, Microsoft 365 Copilot, Gemini and Grok
  • The agent then walks you through connecting your own data, one source at a time
  • A downloadable copy with the flow chart, the rules and the full guide
Get access to this agent

An example run

What happensIn June, a therapy practice had 37 denials. Twenty-two lacked the telehealth modifier. The agent corrected them and they passed payer edits. Four failed the edit check because treatment plans lacked signatures, so the therapist signed them before resubmission. The biller approved all 26. Two weeks later, 24 were paid; the agent drafted second-level appeals for the other two.

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