AI Agent for Claims Processing

OpenBots Claims AI Agent automatically reviews, generates, validates, and routes healthcare claims by fully automating the steps that are traditionally handled by human claims processors, coders, and billers.

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Here’s a Deep Breakdown

Here’s a deep breakdown of what such an AI agent typically does and how it can be architected:

Core Functions

Experience the power of automated remittance processing

1

Claims Intake & Parsing

Intelligent processing of multiple claim formats with advanced parsing capabilities.

  • X12 837 and HL7 format processing
  • PDF and faxed image recognition
  • Portal exports and batch processing
  • Real-time data extraction
2

Data Validation

Comprehensive validation against multiple databases and rule sets for accuracy.

  • Checks patient demographics against eligibility databases.
  • Validates provider NPI, taxonomy, and licensure.
  • Cross-references CPT/HCPCS codes with ICD-10 diagnoses for medical necessity.
  • Applies payer-specific rules and fee schedules.
3

Automated Adjudication

Smart claim processing with payer integration and intelligent coding logic.

  • Payer API integration
  • Missing modifier identification
  • Upcoding/downcoding optimization
  • Attachment requirement flagging
4

Denial Prevention & Resolution

Predictive analytics and proactive resolution for maximum claim success.

  • Predicts likelihood of denial using historical claim data.
  • Flags potential missing documentation before submission.
  • Suggests appeal templates and supporting evidence for denied claims.
5

Communication & Submission

Seamless integration with clearinghouses and automated status tracking.

  • Direct submission to clearinghouses or payer portals.
  • Tracks claim status and automates follow-ups (chatbot-style or API-based).
  • Sends EOB/ERA data back to practice management systems.
6

Analytics & Reporting

Comprehensive insights and real-time dashboards for performance optimization.

  • Provides real-time dashboards on claims aging, denial trends, and payer performance.
  • Highlights bottlenecks in RCM workflow.
  • Real-time claims aging reports

From a technical requirements and scoping perspective, it’s been excellent working with the team. I appreciate how detail-oriented they are and how clearly they define what they want to achieve. Overall, it’s been such a positive experience working with OpenBots!  

Theresa Jackson Director of Technology, Complete Care Centers
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