Solutions / AI Claim Review
AI Claim Review
Every claim scored for denial risk before submission — errors fixed upstream, not appealed downstream.
Most claim review happens after the denial, when the revenue is already stalled. GetMax reviews every claim before it leaves — scoring denial risk against payer behavior, flagging the missing field, the coverage gap, the code conflict — so problems get fixed while they're still cheap.
How the AI works
- 01
Score
Each claim checked against payer rules, historical denial patterns, and its own data completeness.
- 02
Flag & fix
Specific issues surfaced with the fix — not a generic 'review this claim' task.
- 03
Learn
Every real-world denial feeds back into the model, so the same miss doesn't repeat.
Humans in the loop. By architecture.
High-risk claims aren't silently auto-corrected — they're fixed with a visible reason, and unusual patterns route to billing specialists for judgment.
Questions, answered
What kinds of issues does it catch?+
The classics that become CARC denials: missing or inconsistent information (CO-16), coverage and coordination issues (CO-22), bundling conflicts (CO-97), medical-necessity mismatches (CO-50), and payer-specific formatting problems.
Does it slow claims down?+
No — review happens in the submission pipeline. Clean claims pass straight through; only flagged claims pause, and they were the ones that would have bounced anyway.
More of the engine:AI Medical Coding,AI Documentation,AI Workflow Automation,Staff Augmentation,Business Process Outsourcing,Automation Services,GetMax RCM Platform,AI Coding Assistant,Denial Analytics,Practice Dashboard,Revenue Intelligence,Patient Eligibility Platform,Claims Management,Reporting & Analytics
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