Medical reviewers, nursing staff, and clinicians are required to examine medical records for claims and verify patient data related to prior authorizations and claims, also respond to specific questionnaires associated with each claim. Currently, this process is conducted manually, where they meticulously scrutinize each document to verify its accuracy and provide responses to the questionnaire. To assist in their assessments, they refer to both the provided claim document and the CMS document. Subsequently, based on their findings and responses to the questionnaire, they make recommendations regarding the claim as approval, denial or requesting further information. The duration of this entire process varies from a few hours to several days, depending on the number of pages in each document. 

Our medical review solution, developed with the assistance of GenAI, streamlines this process by employing an LLM to automatically respond to questionnaires. This solution helps the nursing staff to improve their productivity by 30-50% by automating the review of medical records. 

Anonymous nationwide payer client

Government payer entity

• Insurance verification
• MBI lookup
• Insurance discovery
• Coordination of benefits (COB) checks

• RCM vendors
• EHR/EMR
• PMS vendors
• Provider groups