The Claim Recovery Agent is a premium service of the Recovr product by Pinnacle Services Corporation. It is an AI-powered system designed to automate the recovery of medical claim denials. It can identify the root cause of a denial, determine the recovery steps, and complete actions to resolve denials for a given claim.
The agent has real-time access to the following information sources and data tools for analysis:
- Claim and Remittance Advice
- Patient Billing History
- Real-time Patient Eligibility and Benefits Status Checks
- Real-time Insurance Discovery Service
- Real-time Coordination of Benefits Discovery Service
- Provider NPI Information Database
- Current NCCI Edits Database
- Current LCD/NCDs Database
- Payer Policy Databases (over 2,000 documents)
- Payer Contracts and Fee Schedules (if loaded for the provider NPI)
- Appeal Letter Templates
- Pathology Coding Handbook
The agent can perform the following actions beyond just providing answers:
- Create information request letters to providers.
- Update claim fields for refiling.
- Create appeal letters with specific reasons and policy citations.
The agent can run analysis and recovery tasks with the following control options:
- Full Autonomy Mode: The agent will automatically perform actions to recover claims from a list of denials.
- Fully Manual Mode: The agent will interact with the user via a chat application and provide answers and complete actions based on user input.
- Human-in-the-Loop Mode: The agent will prepare actions but will require the user to execute them (e.g., sending letters or resubmitting claims to the payer).
The following data is required to set up the agent:
- Required: Copies of standard HIPAA EDI 837 and 835 files for claims and remittances (12 months of data is preferred for best results).
- Optional: Provider-specific payer contracts and fee schedules for more precise answers.
Startup Time: Within 48 hours after EDI files are available.