Total Batch Volume
3 Claims
Total Value: $4,550.00
Dollar Exposure at Risk
$4,365.00
2 high/critical claims pending correction
Average Denial Probability
75.0%
Predicted across current payer batch
Pre-Submission Clean Rate
0%
Ready for first-pass adjudication
Pre-Submission Claims Batch
3 Claims
| Claim ID | Patient | Specialty & CPT | Payer | Billed ($) | Filing Window | Predicted Risk | Action Status |
|---|
Systemic Root-Cause Prevention Analysis
CareCloud AI RCM Loop: Moving from reactive appeals to pre-bill root-cause elimination.
1. Denial Signal
→
2. AI Pattern Analysis
→
3. Root Cause Isolation
→
4. Workflow Change
→
5. Pre-Submission Prevention
Prior Authorization Gaps
Payer: Aetna
Specialty: Behavioral Health (CPT 90837). Repeated claims failing because outpatient psychotherapy exceeding session thresholds lacks active precertification.
Permanent Fix: Integrate automated authorization verification into EHR scheduling intake.
Eligibility Lapses & High Dollar Scrub
Payer: UnitedHealthcare
Specialty: Orthopedics (CPT 27447). Major joint reconstruction submitted without 270/271 real-time benefit eligibility check within 48 hours of surgery.
Permanent Fix: Enforce hard EDI 270 eligibility freeze 24h prior to surgical admissions.
Timely Filing Expiration Risk
Payer: Medicare Part B
Evaluation & Management (CPT 99214). Impending Medicare filing limit expiring within 4 days due to documentation hold queues.
Permanent Fix: Configure automated alert queue at 15-day filing threshold.