Medical claims audit with AI

Is this billed service medically necessary?

Medical claims audit software for payers and insurers: upload the medical record and the billed service; the AI flags what could lead to a claim denial and the auditor decides.

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Want to audit your own claims? Book a pilot

Clinical record + medical order · Max 20 MB

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Reviewed by: Arkangel AI clinical review team, Medical claims audit and medical necessity content

What is an AI medical claims audit?

An AI medical claims audit checks invoices, supporting documents and medical records with administrative, clinical and financial rules to flag possible claim objections, such as lack of medical necessity. Arkangel AI links each finding to its source text; when there is no certainty the result is "not verified", never an automatic denial. The human auditor makes the final decision.

Claims auditing for health plans, TPAs and providers

The same medical claims audit, from each side of the claim.

Health plans and insurers

Audit claims against medical records, coverage rules and contracts before or after payment, with each finding linked to its evidence.

TPAs and self-funded employer plans

Third-party administrators that process claims for employer plans can apply the plan's rules consistently and keep a traceable record of each finding for the plan sponsor.

Hospitals and providers

Audit your own claims before billing to find missing documentation or medical-necessity gaps that could lead to denials.

Reviewing claims before they are paid? Healthcare payment integrity and prepayment review

AI medical claims audit vs. manual review

How AI-assisted review supports a more complete and traceable claims audit.

NeedArkangel AIManual review
Claims coverageApplies the rules to every claim in the batch, not just a sampleUsually reviews a sample or only the highest-value claims
Evidence reviewPuts diagnosis, symptoms, prior workup and justification next to what was billedRequires assembling evidence from long supporting documents
Audit cycle98 deterministic rules in three layers, with each finding's evidence in front of the auditorDepends on queue size and supporting documents
TraceabilityEach finding keeps its proposed reason and the source textDepends on notes written after the review

Book a payer pilot

We walk through your audit process and scope a pilot on a sample of your own claims.

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Mayo Clinic
Mount Sinai
Cleveland Clinic
MD Anderson
IEEE
Novartis
Boston Scientific
Novo Nordisk
Elsevier
Johnson & Johnson
Knight Foundation
AstraZeneca
Boehringer Ingelheim
Bristol-Myers Squibb

Medical claims audit that scales

Support your auditors with AI: check record evidence against what was billed to spot possible medical-necessity objections. The final decision stays with the auditor.

Explore potential documentation gaps

Review available, supported records for potential billing details and documentation gaps. Validate findings against the complete clinical context.

Evidence at your fingertips

Explore available clinical guidelines and literature, and check the sources and relevance of each finding before applying it.

Findings for clinical review

Surface potential clinical risks and documentation gaps in supported records for professional review. Timing and coverage depend on the configured workflow.

Review potential billing gaps

Identify possible missing charges or coding gaps in supported records. Billing professionals validate the documentation and applicable payer rules before making changes.

Security & Compliance

ISO 27001 Certified. HIPAA on Enterprise.

70+ security controls, penetration tested, and continuously monitored via Vanta.

Compliance Center

ISO 27001:2022 certified and penetration tested, with HIPAA compliance and a BAA on Enterprise plans. With 70+ security controls covering infrastructure, data privacy, and audit procedures—plus continuous monitoring via Vanta—Enterprise deployments protect PHI with cryptographic controls and information access restrictions.

Security & compliance

Built for Healthcare Teams

Role-based access control, secure development policies, and system change procedures let your team collaborate safely. Scale across departments with audit trails, asset handling controls, and subprocessors like Azure for anonymization—all documented in our public Compliance Center.

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Questions about AI medical audit

Find answers to common questions about Arkangel AI

AI reviews clinical records and supporting documents, compares them with what was billed or requested, and prioritizes cases with possible inconsistencies, denials or medical-necessity issues. Arkangel AI links each finding to its source text so the auditor can validate it; the final decision always stays with the human auditor.

Look for solutions that combine document reading, administrative, clinical and financial rules, and human validation. Arkangel AI runs 98 deterministic rules (27 administrative, 29 clinical and 42 financial), delivers each finding with its evidence and reason, marks as "not verified" what it cannot confirm, and the human auditor decides.

Medical necessity review checks whether the clinical record justifies a requested or billed service, based on symptoms, prior workup and applicable guidelines. Reviewing documentation before authorization or billing reduces avoidable denials; Arkangel AI organizes the evidence and flags missing documentation for qualified reviewers.

A medical claims audit checks a billed claim against the medical record, the payer's rules and the contract to confirm that services were documented, medically necessary and billed correctly. Health plans and TPAs audit claims to find payment errors; providers audit their own claims before billing to prevent denials. Arkangel AI applies the rules to every claim in a batch and the auditor decides.

AI reads the claim, the invoice and the supporting documents, applies administrative, clinical and financial rules, and returns each finding with its source text. What it cannot confirm is marked "not verified" for a human auditor; Arkangel AI never denies a claim automatically.