AI claims-readiness review

AI Review

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

Patient A.K.

Cardiology · Cardiac Sciences

Medium-high risk

Case type

Cashless insurance

Stage

Discharge pending

Procedure

PCI with stent

Payer / TPA

Private Insurance / TPA

Claim readiness score

68/ 100

Claim packet needs back-office review before final TPA 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

₹6.7L

Requires hospital review

Stent invoice not clearly linked to cath lab report

₹3.1L at risk

Claim impact: Stent cost may be deducted if linkage isn't clear at claim review
Why it matters: TPAs commonly deny or reduce implant reimbursement when stent type, quantity, and vessel treated aren't traceable across cath lab report and invoice.
Supporting evidence needed: Cath lab report, stent invoice, and procedure note cross-referenced by stent serial / batch

ICU stay justification incomplete

₹1.5L at risk

Claim impact: ICU bed and monitoring charges at risk of partial approval
Why it matters: Without documented monitoring reason and clinical justification, ICU stay is a frequent deduction target.
Supporting evidence needed: Discharge summary entry explaining ICU monitoring reason and duration

Consumables not referenced in procedure documentation

₹1.2L at risk

Claim impact: Consumable line items may be queried or deducted from final bill
Why it matters: Consumables billed but not mentioned in procedure or cath lab notes are typically disallowed.
Supporting evidence needed: Procedure note or cath lab record listing consumables used during PCI

Investigation evidence not linked to PCI indication

₹0.9L at risk

Claim impact: Procedure indication may be queried, delaying TPA clearance
Why it matters: ECG and troponin findings must clearly support the indication for PCI to avoid medical-necessity queries.
Supporting evidence needed: ECG and troponin reports referenced in indication for procedure

Before vs. after back-office fixes

Before AI Review

Claim readiness

68/100

Revenue at risk

₹6.7L

Medium-high deduction risk

After back-office fixes

Projected

Claim readiness

91/100

Revenue at risk

₹1.1L

Ready for TPA submission

Documents on file

6 uploaded

Discharge summary

Cath lab report

Stent invoice

ECG / Troponin report

Final bill

TPA query note

Not ready for final submission

Discharge clearance workflow

Documents uploaded

Step 1

AI review completed

Step 2

Gaps identified

Step 3

Back-office action required

Step 4

Ready for TPA submission

Step 5