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For RCM Teams — Agentic AI Platform

RCM Agent Orchestrates
the Work. Skills Get It Done.

The RCM Agent routes each task to specialized Skills like Prior Auth and Appeals, with more on the way.

See It In Action How It Works →
RCM Agent
Prior Auth Skill
Active
Appeals Skill
Active
More Skills Coming
Coming Soon
The Agent orchestrates. Skills execute.
RCM Agent — Prior Auth

Denial assessment & AI recommendations that give your analysts 10x productivity

The Prior Auth RCM Agent assesses every prior authorization denial, identifies the root cause, and delivers a precise AI-recommended action plan — so your analysts spend their time executing, not investigating. What used to take 45 minutes now takes under 5.

✓Instant denial assessment — root cause identified the moment a claim is denied
✓AI-generated action plan tailored to the denial type, payer, and applicable SOP
✓Guides analysts through CPT mismatches, field locator 63 errors, retro auth, and 3rd party failures
✓New analysts productive from day one — no institutional knowledge required
10x
Analyst productivity increase
45→5min
Per prior auth denial worked
Prior Auth Agent — Active
AI AGENT
✓
Denial analyzed — root cause identified
CPT mismatch detected. Auth approved for 27447-LT, claim billed 27447-RT (laterality discrepancy).
Invalid Authorization — CPT Mismatch
✓
Payer guidelines retrieved
Aetna allows auth update for CPT laterality corrections within 90 days of DOS. Within timeframe confirmed.
3
Route to coding team for CPT review
Verify if 27447-RT was the correct procedure. If correct, contact Aetna to update auth. If coding error, submit corrected claim.
4
Submit retro auth or corrected claim
Based on coding review outcome — submit retro auth within 90-day window or file corrected claim with updated CPT.
5
Document outcome and close
Update account notes, log resolution action, confirm reprocessing or payment posted.
RCM Agent — Appeals

AI-drafted. Human-approved.
Faster than ever.

The Appeals Agent handles research, drafting, documentation assembly, and batch queuing — autonomously. Your analysts review every appeal before it goes out. Nothing leaves without explicit human sign-off. Every appeal. Every time.

Avg appeal build time — before45 min
Avg appeal build time — with agent< 2 min
Appeal success rate76%
Human review before sending100% Always

What the agent does

✓Researches payer criteria and denial context automatically
✓Drafts payer-specific appeal letters using denial reason, auth history, and clinical context
✓Pre-populates required payer forms from claim data — no manual entry
✓Bundles letter + forms + documentation into one file for payer portal upload
✓Batches and prioritizes appeals by deadline, payer, and denial amount
✓Every appeal requires analyst review and approval before sending — no exceptions
Core Agent Skills
01
Payer-Specific Letter Drafting
AI generates appeal letters using denial reason codes, claim details, authorization history, and clinical context — with payer-specific formatting and language applied automatically.
AI Automated
02
Payer Form Pre-Population
Required payer forms auto-populated from claim data. Analysts review a fully assembled package — no manual entry, no hunting for the right form, zero re-keying of data.
AI Automated
03
Documentation Bundle Assembly
Appeal letter + payer forms + clinical documentation consolidated into a single file, ready for one-click upload to the payer portal — no manual packaging.
AI Automated
04
Batch Queue Management
High-volume appeals batched and prioritized by filing deadline, payer, and denial amount. Analysts review in urgency order — no missed timely filing windows.
AI Automated
05
Mandatory Human Review Gate
Every appeal is held in a review queue until an analyst explicitly approves it. Nothing is sent autonomously. Full compliance control stays with your team — always.
Human Required
06
Win Rate Analytics by Reason Code
Tracks which denial reason codes produce successful appeals and which need a different strategy — your team continuously improves quality and win rates over time.
AI Automated
Live Analyst Review Queue

Pending Analyst Review

3 awaiting approval
APL-0441$4,200
United Health · CO-15 · CPT 99285 — ED E&M Level 5
AI NoteAuth #UHC-PRE-774821 obtained prior to DOS. Inadvertently omitted from field locator 63. Letter requests expedited reprocessing with enclosed authorization confirmation.
APL-0442$18,450
Aetna · CO-15 · CPT 27447 — Total Knee Replacement
AI NoteLaterality correction applied. Auth updated to 27447-RT. Retro auth submitted. Appeal references Aetna §4.2.7 — within 90-day correction window confirmed.
APL-0443$9,100
BCBS · PR-96 · CPT 93306 — Echo w/ Doppler
AI NoteMedical necessity documentation attached. Clinical notes from ordering physician included. Standard BCBS appeal template applied per payer guidelines.

Approved & Sent Today

12 sent
APL-0438$24,800
United Health · CO-15 · CPT 99213
✓ Approved by J.S. · 9:14 AM · Sent to UHC portal
APL-0436$6,400
Humana · PR-204 · CPT 70553
✓ Approved by M.K. · 8:52 AM · Sent to Humana portal
APL-0434$12,200
BCBS · CO-4 · CPT 90834
✓ Approved by J.S. · 8:31 AM · Sent to BCBS portal
APL-0430$3,900
Cigna · CO-97 · CPT 99214
✓ Approved by R.T. · 8:10 AM · Sent to Cigna portal
100% Human Review
Every appeal approved before sending — no exceptions
Payer-Specific Format
Auto-formatted per each payer's requirements
2 Min Draft Time
Down from 45 minutes of manual build time
76% Win Rate
Across all payers and denial reason codes
Frequently Asked Questions

Everything you need to know

Questions about the RCM Agent, Prior Auth Skill, and Appeals Skill — answered.

Prior Auth Denials
The moment a prior auth denial arrives, the agent reads the CO/PR reason codes and instantly classifies the root cause — CPT mismatch, invalid authorization, no auth on file, or laterality discrepancy. It then retrieves the applicable payer policy and generates a step-by-step action plan for your analyst. No manual research required.
The Prior Auth Skill handles invalid authorization, no auth obtained, CPT/laterality mismatches, field locator 63 omissions, retro auth scenarios, and third-party authorization failures from Evicore, Carelon, and Turning Point.
The agent detects the discrepancy between the authorized CPT code and the billed code, retrieves the payer's correction policy, and routes the claim to your coding team with exact instructions — specifying whether to submit a corrected claim or update the auth with the payer directly.
What previously took an analyst 45 minutes to research and action is reduced to under 5 minutes with the Prior Auth Agent. That's a 10× productivity increase per denial worked.
Appeals
The Appeals Agent uses the denial reason code, claim details, authorization history, and clinical context already in the system to generate a payer-specific appeal letter — formatted and worded per that payer's requirements. The full draft is ready in under 2 minutes.
Yes — without exception. Every appeal drafted by the agent is placed in a review queue. An analyst must read, edit if needed, and explicitly approve before anything is submitted to a payer. The agent drafts and assembles; humans authorize and send.
Each appeal package includes the payer-specific letter, pre-populated payer forms, and supporting clinical documentation — bundled into a single file ready for one-click upload to the payer portal. No manual assembly needed.
Appeals are batched and sorted by filing deadline urgency, payer, and denial dollar amount. Analysts always work the highest-risk appeals first so no timely filing window is missed due to queue backlog.
The Appeals Agent achieves a 76% success rate across all payers and denial reason codes — compared to an industry average of 45%. Win rate analytics by reason code help your team continuously refine appeal strategy over time.
RCM Agent
The RCM Agent is the central orchestrator in Denials 360. It receives incoming denial work, determines which specialized Skill is needed, routes the task accordingly, and ensures every action is logged. Think of it as the coordinator that activates the right expert for each job.
The RCM Agent is the orchestrator — it decides what needs to happen and routes work. Skills are the specialized modules that execute specific tasks. The Prior Auth Skill handles authorization denials; the Appeals Skill handles drafting and submission. The Agent calls the right Skill for each denial type.
Two Skills are live today: the Prior Auth Skill for denial assessment and action planning, and the Appeals Skill for AI-drafted, human-approved appeal generation. Additional Skills covering other denial types and RCM workflows are in development and coming soon.
No. The RCM Agent and its Skills are designed to augment your analysts — handling the time-consuming research, classification, and drafting so analysts can focus on decisions, reviews, and approvals. Every appeal still requires human sign-off before it leaves your team.
The RCM Agent with Prior Auth and Appeals Skills is available as an additional module on any Denials 360 plan. Contact the DataRovers team to enable it for your organization.

Ready to recover more revenue?

The denial management platform built for healthcare RCM teams. Prior auth, retro authorization, field locator 63, CO and PR denial codes, timely filing. Your team productive on day one.

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