HealthyClaim is a healthcare billing intelligence and research platform in public preview, exploring how AI-assisted clinical evidence extraction can work with deterministic verification to produce evidence-backed coding and claim artifacts. Instead of allowing probabilistic AI models to make unverified billing decisions, HealthyClaim isolates clinical fact extraction from deterministic rule adjudication.
Medical billing cannot tolerate black-box guesswork. HealthyClaim separates clinical evidence extraction from deterministic rule adjudication.
Deterministic Adjudication Architecture. AI models extract documented clinical facts; deterministic code evaluates candidate codes against CMS NCCI edits, CMS MUE data, and Medicare coverage policies. Every code candidate maintains traceability to documented facts.
Comprehensive Evidence Capture. Evaluates documented MDM complexity and encounter time for E/M candidates, evaluates Modifier 50 bilateral criteria, checks drug waste documentation (JW/JZ), and evaluates qualifying add-on services.
Public Demo Uses Synthetic/De-identified Examples — Do Not Submit PHI. Our public research demo operates exclusively with synthetic clinical scenarios. Enterprise security and data-handling requirements will be addressed during pilot onboarding.
Designed for Standard Interoperability. HealthyClaim is being developed to work alongside standard healthcare documentation workflows, generating draft artifacts in standard CMS-1500 and ANSI 837 EDI formats.
Clear boundaries are essential when applying AI to healthcare revenue cycle intelligence.
We never permit probabilistic language models to hallucinate or guess billing codes. Candidate codes must be deterministically grounded in extracted clinical facts and authoritative code sets.
AI is restricted to bounded linguistic evidence extraction. All coding, unbundling, modifier, and unit determinations are computed deterministically by verified rules.
HealthyClaim generates draft claim artifacts (CMS-1500, EDI 837P) for evaluation, testing, and downstream clearinghouse intake — not live electronic claim transmission.
When clinical documentation is ambiguous, the system surfaces clarification requests rather than making silent guesses. Certified coders retain final oversight.
Every single claim runs through five sequential accuracy gates before an artifact is generated. No single point of failure. No unverified assumptions.
De-identifies and extracts factual clinical observations (symptoms, diagnoses, procedural details, anatomical laterality, and encounter duration). Filters out historical or ruled-out conditions to prevent false claims.
Evaluates Column 1 and Column 2 unbundling conflicts against official CMS NCCI tables. Determines modifier eligibility and enforces strict practitioner and facility MUE unit ceilings.
Validates diagnostic medical necessity against official Medicare Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) to identify non-covered indications.
Computes the documented E/M level via 2-of-3 MDM matrix and time analysis; evaluates Modifier 50 for bilateral criteria; splits JW/JZ drug waste per CMS Ch.17; and applies the 8-minute therapy remainder rule.
Performs 5010 structural validation, diagnosis pointer mapping (1–4 pointers per line), POS facility vs non-facility rate checks, and generates draft CMS-1500, UB-04, and ANSI 837 EDI files for testing.
Eliminate hours of manual chart reading, coding lookups, and modifier calculations. HealthyClaim ingests raw clinical narratives and outputs draft claim packages structured for testing and workflow evaluation.
Handles SOAP notes, comprehensive H&Ps, operative reports, ED logs, discharge summaries, and scanned PDF clinical records.
Evaluates documented E/M complexity, applies Modifier 50 bilateral rates, and captures qualifying add-on services.
Automated JW/JZ drug waste line separation per CMS rules and remainder-priority 8-minute rule allocations for physical/occupational therapy.
Inspect and download draft CMS-1500 PDFs, UB-04 claim forms, and standard EDI 837P / 837I files for workflow testing.
See how raw clinical text is converted into candidate codes, evaluated against CMS NCCI and MUE rules, and packaged for evaluation.
CHIEF COMPLAINT: Severe bilateral knee pain, right worse than left.
HISTORY: 67yo male with severe bilateral knee osteoarthritis failing 6 months of conservative PT & NSAIDs. Inability to walk >1 block.
EXAM: Severe crepitus right knee, limited ROM (0-85 deg), lateral joint space narrowing on X-ray confirmed bone-on-bone.
DECISION: High MDM. Total Right Knee Arthroplasty scheduled. Depo-Medrol 80mg injection administered for interim relief.
From pre-submission claim generation to post-denial appeals, HealthyClaim covers the full spectrum of revenue cycle operations.
Convert raw clinical notes into draft CMS-1500 and UB-04 claims in seconds. NCCI, MUE, and modifier rules are resolved deterministically before downstream processing.
Map documented clinical evidence directly to payer-specific medical coverage criteria. Identify missing diagnostic tests or documentation gaps before submission.
Import remittance denials, classify root causes via CARC/RARC codes, reconstruct the original claim, and generate draft appeal letters with Medicare policy citations.
A comprehensive pre-clearinghouse gate: evaluates syntax, structural format, clinical coding, payer adjudication rules, and predictive denial risk before transmitting an EDI batch.
Our platform does not rely on speculative AI guessing. Every candidate code evaluation is calculated deterministically against official CMS NCCI, MUE, and Medicare coverage datasets.
Watch workflow demonstration videos showing how HealthyClaim assists clinical documentation and billing workflows.
Real-Time Eligibility Verification: HealthyClaim checks patient coverage status and plan benefits directly inside the workflow — demonstrating automated benefit verification.
Automated Prior Authorization: Cross-reference clinical notes against payer coverage policies, assemble clinical documentation, and generate evidence-backed PA requests.
Intelligent Claim Appeals: When denials occur, HealthyClaim drafts targeted appeal letters citing specific LCD/NCD coverage policies and patient clinical records.
Public Demo Uses Synthetic/De-identified Examples — Do Not Submit PHI. Enterprise security and data-handling requirements will be addressed during pilot onboarding.
Connect with our clinical intelligence specialists to see how HealthyClaim Code & Bill can streamline your revenue cycle.
Explore HealthyClaim's research platform. Review synthetic clinical documentation or request an enterprise technical briefing.
HealthyClaim is developing deterministic healthcare revenue cycle intelligence to eliminate billing errors and unsupportable audit risk. We welcome conversations with healthcare leaders and researchers.