Health insurance appeal management
Appeals management for a health plan: a verification inbox where key fields extracted from the appeal PDF are checked against their citation and corrected by clicking the section, a review inbox with the claim, the member and the AI recommendation with its logic chain, an approve or deny decision, and the letter generated from the organisation's approved template and sent.
One working session with the people in the seat: which decisions, which systems, what a good week looks like.
The app you see above, running on your own exports instead of the simulated world. Every screen, every decision, your numbers.
Wired to your systems with your permissions, agents proposing, people approving, the ledger recording who did what.
Overview
Appeals arrive as long, non-standard letters. A coordinator reads each to find the claim and member, then reads it again against the policy to recommend a decision, and writes the response from a template by hand.
The control center extracts the key fields from each appeal with a citation to the page section; the coordinator verifies or edits them by clicking the section, and every edit is tracked for auditors. Verified appeals move to review, where the claim and member are pulled from the sources of truth beside the AI's recommendation and reasoning under approved guidelines. Approve or deny generates the letter from the template with the chosen reason and the coordinator's notes, then sends it.
Key features
- Verification assistant inbox: extracted key fields with direct references to the appeal, edited in context with tracked changes.
- AI integrated review inbox: claim, member and the decision recommendation with its logic chain.
- Letter generation: approval and denial letters from organisation-approved templates with reasons and notes.
- Expedited handling: urgency tracked across the inboxes.
Decisions it produces
- Verify or correct an extracted key field
- Move an appeal to review or mark it invalid
- Approve or deny the appeal
- Send the generated letter
Data sources
| Appeal letters | PDF text with section citations |
|---|---|
| Claims system | claim, diagnosis, charges, plan |
| Member system | member details and coverage |
| Guidelines | organisation-approved decision policies |
Simulated data throughout. Book a call to see it on your own systems.
Related demos
Hospital claims denials management
Denials management for a hospital: choose a denied encounter, generate the appeal letter from the chart notes and care guidelines with the reasoning shown, edit and submit it, a template that trains the letter style from real examples, and statistics on letters submitted and time saved.
Claims coverage engine
A coverage engine for private liability claims: claims selected for checks, the checks running against coverage conditions written in natural language, results per condition with the reasoning and the identified customer, and the conditions themselves added, modified and tested on a claim, with the guardrail that no payout is refused without a human confirming.
Health insurance utilization review
A utilization review assistant for hospital case managers: patients by department, a three-step flow that selects the source notes, chooses the diagnosis and its objective criteria from care guidelines and payer requirements, and generates the initial or concurrent review draft with the reasoning shown, for the case manager to edit, save and send to the insurer.