Claim Scrubbing Agent

Claims rejected by a payer delay cash and cost staff time to rework. Before claims are sent, this agent checks each one. It compares diagnosis and procedure codes for medical necessity matches and checks modifiers, units, place of service, provider details and patient insurance details. It applies payer-specific rules. A claim whose diagnosis does not support the procedure, or that lacks a required payer modifier, is held. Errors go to a fix list with the reason. The biller corrects them and the agent rechecks until each claim passes every edit. Clean claims are batched, and the biller approves every batch and any code change. After submission, it reads clearinghouse rejections, and when the same rejection appears three times it adds a new rule. Edge case: a payer needs a specific modifier for telehealth visits, so the agent applies that payer's rule only.