Review supported documentation for potential medical-necessity and coding gaps before submission when your workflow allows. Findings require human validation and do not guarantee payment or prevent audits.
Last updated:
Payer requirements vary across contracts and billed services. Missing signatures, unsupported medical necessity and inconsistent coding can leave claims without the documentation needed for review.
Payer audits may follow unusual billing patterns, duplicate claims or documentation that does not support the billed service. Requirements vary by payer and contract. Reviewing available records before submission can help teams identify potential gaps, but findings need human validation and cannot guarantee payment or prevent an audit.
High CPT volumes, peer comparison concerns, and duplicate claims trigger payer investigations that can result in extensive audits.
Incomplete treatment plans, unsupported medical necessity, and missing signatures create vulnerabilities that auditors exploit.
Prior authorization gaps, LCD/NCD violations, and state/federal regulatory non-compliance expose organizations to significant financial risk.
Compare available, supported records with configured payer criteria and surface potential documentation gaps with evidence. Your team decides which findings require correction or further review.
AI compares supported records available to the configured workflow with selected payer policies and documentation criteria. It surfaces potential coding or medical-necessity gaps with evidence for the responsible team to validate. Review before submission depends on data availability and integration timing; payment decisions and audit outcomes remain with the payer.
Compare supported records with configured payer policies and documentation criteria, including applicable LCD/NCD requirements. The responsible team validates findings before taking action.
Surface documentation gaps that may warrant repayment review. Validate findings against the applicable contract and clinical record before deciding whether a claim requires correction.
Establish a documented review process for payer criteria, with evidence and a responsible reviewer for each potential gap.
Define criteria, connect supported records and agree how your team will review findings.
Work with the implementation team to configure applicable payer contracts, LCD/NCD criteria and review thresholds. Connect supported documentation sources, then review the resulting evidence and reports with the responsible billing or compliance team. Coverage and delivery timing depend on the agreed integration; findings require validation before any claim correction.
Work with a dedicated engineer to configure payer-specific rules, LCD requirements, and compliance thresholds for your organization.
Apply the selected criteria to documentation available in the configured workflow and flag potential exceptions for review.
Organize potential findings and their supporting evidence into reports for the responsible billing or compliance team. Agree who reviews each report and validates any proposed correction before submission.
How AI pre-bill review compares with traditional human auditing on coverage, speed, and cost.
Manual review depends on reviewer capacity and may use sampling. AI can help apply configured criteria to supported records available in the workflow, surfacing potential issues for human validation. The appropriate approach depends on your sources, volume, staffing and timing; neither coverage nor financial outcomes are guaranteed.
| Capability | Arkangel AI | Manual auditing |
|---|---|---|
| Chart coverage | Supported records available to the workflow | Coverage depends on reviewer capacity and sampling |
| Turnaround | Feedback after processing; timing varies by workflow | Days to weeks, after submission |
| Consistency | Configured criteria applied to supported inputs | Varies by auditor and workload |
| Cost | Cost depends on volume, plan and human review | High, labor-intensive headcount |
| Audit readiness | Traceable findings for review and audit preparation | Manual prep for each audit |
Estimate for your workflow
Compare expected processing costs with your current review process using your own volume, staffing and validation needs. Savings vary.
Health plans, TPAs and providers use the same review from different sides of the claim.
Run prepayment review on high-risk claims and postpayment audits on paid ones, with the evidence for each finding in front of the reviewer.
Apply the plan sponsor's rules consistently across the claims you administer and keep a traceable record of every finding.
Check claims against payer criteria before submission to close documentation gaps that lead to denials and recoupments.
Two moments to protect payment integrity: before a claim is paid and after.
Prepayment review checks a claim and its supporting documentation before the payer releases payment. It catches billing errors, missing documentation and unsupported medical necessity while the claim can still be corrected, instead of recovering money later. It has to fit within the payer's payment deadlines.
Before payment: flag claims whose documentation does not support what was billed, request records or route them to a clinical reviewer. Avoids pay-and-chase recovery.
After payment: audit paid claims by sample, outlier pattern or provider and recover overpayments. Looks further back, but recovery takes time and strains provider relations.
Auditing claims line by line against the chart? Try the medical claims audit demo
See how much you could save with AI-powered compliance review
Calculate your potential annual savings from implementing AI-powered documentation review based on your team size and hourly rates.
Discuss your payer policies, data sources and review process with our team to assess whether the configured workflow fits your needs. Payment and audit outcomes remain outside the product’s control.
Schedule a DemoWant to see what a cited finding looks like on a sample chart? Explore AI medical record review
Everything you need to know about chart intelligence for payer compliance
Discuss your payer policies, data sources and review process with our team to assess whether the configured workflow fits your needs. Payment and audit outcomes remain outside the product’s control.