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.

RCM Agent
Action Plan
ACTIVE
Appeals Skill
ACTIVE
Prior Auth Skill
ACTIVE
More Skills Coming
COMING SOON

— The Agent orchestrates. Skills execute. —

Agent Skills

Modular skills, purpose-built for RCM

Each skill is a specialized AI capability that plugs directly into your workflows. The Agent orchestrates. Skills execute.

Action Plan

Reads the denial code, payer, service line, and financial data on the claim, then builds a phased plan with one Recommended Action pulled out.

● Active

Appeals

AI-drafted, human-approved. Payer-specific appeal letters assembled in under 2 minutes. Every appeal requires analyst sign-off before it sends.

● Active

Prior Authorization

Assesses every prior auth denial, identifies root cause instantly, and delivers a precise AI-recommended action plan. 45 minutes → under 5.

● Active
RCM Agent · Action Plan

Every denied claim gets a plan, not a guess.

Action Plan reads the denial code, the payer, the service line details, and the financial figures already sitting on the claim, then lays out the exact process your team should follow, phase by phase, instead of a generic denial script.

Claim Snapshot

Claim ID 0048291
Payer Anthem BCBS
Denial Code CO16
Remark Code N290 Missing/invalid rendering provider NPI
Service Line 99213 · Office Visit
Billed Amount $412.00
Status Denied

This is the exact data Action Plan works from. No extra entry, no separate lookup. The plan on the right was generated straight from this record.

Generated Action Plan

1

Verify the Rendering Provider NPI

Remark code N290 narrows CO16 to the rendering provider identifier. Confirm the NPI on the claim matches the provider's active record in NPPES and the payer's credentialing file.

2

Correct and Resubmit

Update the rendering provider NPI in Loop 2310B, NM109, on the 837P and resubmit to Anthem BCBS within the timely filing window.

3

Contact the Payer if Needed

If the resubmission is not acknowledged within 10 business days, open a case with the payer's provider line to verify the NPI is registered under the billing group.

Updated the claim already? Select Regenerate Plan to refresh the phases and the recommended action against the latest data, no need to reread the full plan.

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.

Avg appeal build time — before
45 min
Avg appeal build time — with agent
< 2 min
Appeal success rate
76%
Human review before sending
100% Always

Core Agent Skills

Payer-Specific Letter Drafting

AI generates appeal letters using denial reason codes, claim details, auth history, and clinical context — with payer-specific formatting applied automatically.

AI Automated

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.

AI Automated

Documentation Bundle Assembly

Appeal letter + payer forms + clinical documentation consolidated into a single file, ready for one-click upload to the payer portal.

AI Automated

Batch Queue Management

High-volume appeals batched and prioritized by filing deadline, payer, and denial amount. Analysts work in urgency order — no missed timely filing windows.

AI Automated

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.

Human Required

Win Rate Analytics by Reason Code

Tracks which denial reason codes produce successful appeals — 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 Note — Auth #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 Note — Laterality 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 Note — Medical 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
✓ Approved by J.S. · 9:14 AM · Sent to UHC portal
APL-0436 · $6,400
✓ Approved by M.K. · 8:52 AM · Sent to Humana portal
APL-0434 · $12,200
✓ Approved by J.S. · 8:31 AM · Sent to BCBS portal
APL-0430 · $3,900
✓ Approved by R.T. · 8:10 AM · Sent to Cigna portal
100%
Human review every time
Payer
Specific format auto-applied
2 Min
Draft time vs 45 min manual
76%
Win rate all payers
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.

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 AuthCPT 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.
Frequently Asked Questions

Everything you need to know

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

Prior Auth Denials

How does the Prior Auth Agent assess a denial?
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.
What types of prior auth denials can it handle?
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.
How much time does it save per denial?
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

Does every appeal require human review before sending?
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.
What is included in the appeal package?
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.
What is the appeal success rate?
The Appeals Agent achieves a 76% success rate across all payers and denial reason codes — compared to an industry average of 45%.

RCM Agent

What is the 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.
Does the RCM Agent replace my analysts?
No. The RCM Agent and its Skills are designed to augment your analysts — handling time-consuming research, classification, and drafting so analysts can focus on decisions, reviews, and approvals. Every appeal still requires human sign-off.
Which Skills are available today?
Four Skills are live today: Prior Auth, Appeals, Payer Policy Agent, and Custom Agent Builder. Additional Skills including Coding Assist, Contract Intelligence, and CDI Advisor are in development and coming soon.

Ready to recover more revenue?

The denial management platform built for healthcare RCM teams. Your team productive on day one.