AI claims-readiness review

AI Review

Select a case to review claim readiness, AI findings, back-office actions, and TPA response drafts.

Patient R.S.

Orthopaedics · Orthopaedics / Joint Replacement

High risk

Case type

Cashless pre-authorisation

Stage

Pre-auth pending

Procedure

Total Knee Replacement

Payer / TPA

Private Insurance / TPA

Claim readiness score

62/ 100

Pre-authorisation packet needs back-office review before cashless approval submission.

Revenue at Risk

Revenue at risk represents legitimately billed items that may face deduction, query, or delay if supporting documentation is incomplete.

Potential deduction risk

₹4.8L

Requires hospital review

Implant quote not fully supported

₹2.2L at risk

Claim impact: Implant cost may be partially deducted or queried at pre-auth stage
Why it matters: TPA may reduce implant reimbursement if quotation is not clearly tied to the planned procedure and clinical plan.
Supporting evidence needed: Vendor implant quotation linked to surgical plan and orthopaedic consultation note

Package estimate mismatch

₹1.4L at risk

Claim impact: Approved package may be lower than billed if estimate, room category, and consumables don't reconcile
Why it matters: Mismatch between surgery estimate, room category, and consumables typically triggers TPA query and partial approval.
Supporting evidence needed: Reconciled estimate covering surgeon fee, room category, implant, and consumables

Medical necessity evidence incomplete

₹1.2L at risk

Claim impact: TPA may delay or reduce approval if conservative treatment trail is not documented
Why it matters: Indian TPAs frequently query elective joint replacements without a documented conservative-treatment history.
Supporting evidence needed: Prior consultation notes, conservative treatment trail, and severity findings from imaging

Before vs. after back-office fixes

Before AI Review

Claim readiness

62/100

Revenue at risk

₹4.8L

High deduction risk

After back-office fixes

Projected

Claim readiness

89/100

Revenue at risk

₹0.6L

Ready for pre-authorisation submission

Documents on file

8 uploaded

Doctor consultation note

X-ray report

MRI / imaging report

Planned surgery estimate

Implant quotation

Pre-authorisation form

Insurance policy details

Past treatment history

Estimated cost

₹2,85,000 (package estimate)

Implant details

Cemented TKR implant set — vendor quotation pending reconciliation

Not ready for cashless submission