Denial Appeals
Every appeal answered with the policy wording, the medical record and the reason, cited and on time.
Why it matters
Appeals arrive with new records and letters; reviewers rebuild the original file by hand, and responses miss deadlines or repeat the first reason without evidence.
How the solution handles it
Agents read the appeal, rebuild the claim history, match the wording relied on, summarise old and new medical evidence and watch the clock, then draft a cited response. An appeals physician not involved in the first decision decides and signs.
How an appeal moves
Six agents read the appeal, rebuild history, match wording, summarise records, watch clocks and draft replies; an appeals physician decides and signs.
What it reads, and what it hands back.
What goes in
- Appeal letter and new evidence
- Original claim and denial
- Medical records
- Policy or plan wording
What comes out
- Cited case summary
- Decision letter draft
- External review or ombudsman pack
- Clock on every appeal
Who uses it
The difference, in numbers.
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
target median
Sources: 29 CFR 2560.503-1(i), 30 days for pre-service appeals · KFF analysis of 2023 marketplace data · “Target” = design goal, measured in the live solution · “Typical” = typical industry range today · agents = the live solution’s configuration
6 specialist agents. One person decides.
More in this division.
Every cashless request checked against policy and tariff, ready for a doctor well inside the 1-hour clock.
Discharge SettlementEvery final bill checked against the pre-auth and tariff, so final authorisation lands well inside 3 hours.
Reimbursement ClaimsEvery reimbursement claim read, checked and priced, with a cited file ready for decision in a day.
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