Appeals & Denials | Substrate

Appeals Agent

Hands free records submission, for denied claims, pended claims, and more

Autonomous resolution identifies why a claim was denied, retrieves the required documents from your EHR, validates them against the payer's own policy, builds the appeal package and files it directly through the payer portal.

Live for denials in medical record and eligibility across behavioral health, orthopedics and other specialties with major payers including Aetna, UHC and BCBS.

#284719-1

CPT Paid

99214 CO-50

$0

90837 CO-50

$0

Billed

$1,847

Allowed

$1,564

Paid

$0

Denied

Appeals Agent

Analyzing denial reason...

Retrieving records from EHR...

Verifying patient data...

Building appeal package...

Filing appeal to payer...

Checking claim status...

End-to-end automation
‍Most denial workflows stop at identifying the problem. This agent retrieves records, validates documentation, writes the appeal letter, submits it to the payer portal and monitors until adjudication.

Documents reviewed & attached
The agent categorizes each document, confirms the correct patient and date of service, checks that authorization windows align and extracts the clinical notes that support medical necessity.

Filed Payer Direct
There is no electronic standard for filing appeals. The agent uses automation to navigate payer portals, attach documentation and submit the appeal just as a human would, all with a full video audit trail.

Appeals Agent

How does it work?

From a denied claim to recovered revenue, fully autonomous workflows adjudicate claims with precision and speed

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Denied

Unpaid Claim detected

The claim status agent surfaces the reason it was under-paid, even if it isn't an explicit denial and decides the next recommended action. Appealable denials are seamlessly routed directly to the appeals agent.

Claim Status Agent →

Step 1

Records retrieved

The agent logs into your EHR and downloads the specific documents needed for the appeal: operative reports, visit notes, prior authorizations, imaging results and referral documentation.

Step 2

Documents validated

Each document is categorized, matched to the correct patient and date of service and checked for completeness. Prior authorizations are verified to confirm the service date falls within the approved window.

Document Review →

Step 3

Policy evaluated

The policy agent compares the medical record against the payer's coverage criteria. Each rule is evaluated with a clear yes/no and supporting evidence pulled directly from the clinical documentation.

Payer Policy Review →

Step 4

Appeal packaged

An appeal letter is generated that references the specific payer policy criteria and points to the attached documentation that satisfies each requirement. No generic templates.

Step 5

Filed with payer

The agent navigates the payer portal, uploads the appeal package and submits it. Every action is recorded with screenshots and video for your audit trail.

Paid

Payment Monitoring

The agent periodically checks claim status using EDI, portal agents and EOB retrieval to confirm whether the appeal was accepted and the claim was paid.

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Coverage across denial types. The agent handles the complexity of workflows, requirements and payer specific rules.

Retrieves documents from your EHR including operative reports, visit notes and prior authorizations for only that specific encounter.

Validates against payer policy by checking each medical necessity criterion against what's in the documentation.

Files directly on the payer with the records attached and an appeal letter that references the specific coverage criteria.

Verifies coverage automatically across primary, secondary and Coordination of Benefits through API & direct portal lookups.

Packages proof of eligibility with the original claim data so the payer has everything needed to reprocess.

Monitors through adjudication so corrected claims are always up to date and don't require manual follow-up.

Retrieves the authorization and confirms patient data and verifies the service date falls within the approved window.

Catches mismatches in dates and codes that are prone to human error when authorization windows span disjointed timelines.

Packages the files and uploads attachments directly with the payer with validated dates, codes and supporting documentation.

Built for any structured denial including credentialing, timely filing and coding appeals, constantly expanding use cases.

Inherits the full pipeline from document retrieval through portal submission and post-appeal monitoring, the entire process is covered.

Learns from every outcome to improve which documents to attach and which verbiage work per payer, ultimately leading to better outcomes.

Intelligence behind every agent. The models and data that power every decision.

Eligibility Checks verify patient eligibility for claim routing, COB and eligibility denials in real-time.

Catch issues before they become denials

Verifies coverage prior to submission

Fills COB gaps automatically

Routes claims based on verified eligibility

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Payer Policy Review models and validates your medical records against specific coverage criteria.

Validates documentation before submission

Confirms medical necessity

Compares against payer-specific rules

Generates appeals that reference criteria

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Document Review classifies and extracts data from any medical document automatically.

Faster and more accurate than humans

Identifies & categorizes documents

Extracts billing details & auth windows

Validates patient & claim data

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FAQ

What types of denials does the agent handle today?

Medical record denials and eligibility denials are fully autonomous. The agent identifies the denial, retrieves required documentation, validates it, files the appeal and monitors for payment. Prior authorization and credentialing denials are being added.

Which specialties and payers are supported?

Currently live in urgent care, behavioral health and orthopedics across Aetna, UHC and several Blues plans. Expanding to additional specialties and payers on an ongoing basis.

How does the agent retrieve medical records?

It securely logs into your EHR or PM system using automation, navigates to the correct encounter and downloads the specific documents needed for the appeal. This includes operative reports, visit notes, prior authorizations and imaging results.

How does the policy agent evaluate medical necessity?

It ingests the payer's medical necessity policy, breaks it into scenarios and criteria, then compares each rule against what is documented in the medical record. The output is a structured evaluation with a yes/no for each criterion and the evidence that supports it.

Does a human review the appeal before it is submitted?

The agent handles the full workflow autonomously. When it encounters uncertainty, such as an ambiguous document or a policy rule it cannot evaluate with confidence, it escalates to a human reviewer before proceeding.

How does the agent file the appeal?

There is no electronic standard for filing most appeals. The agent uses browser automation to navigate the payer portal, upload documentation and submit the appeal. Every action is captured with screenshots and video recordings for audit purposes.

How do you monitor the appeal after filing?

The agent periodically checks the claim status using a combination of EDI, portal lookups and EOB retrieval. When the claim is adjudicated, the result and recovered amount are logged and pushed back to your system.

What data do you need to get started?

The same claim data used for claim status, plus access to your EHR for document retrieval and the relevant payer portal credentials. Most teams are live within days.

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