Policy Agent | Substrate

From policy to evaluation

How does it work?

The agent turns dense payer policies into enforceable criteria. Then it runs your records against them automatically, constantly comparing and evaluating

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Setup

Policy Ingestion

Ingest payer medical necessity policies, LCD/NCD documents and coverage determinations into structured, queryable criteria.

Step 1

Scenario Matching

Break each policy into clinical scenarios - new or established patient, initial or follow-up treatment - and match the encounter to the correct one.

Step 2

Criteria Extraction

Extract the conditional rules that must be true for medical necessity. Patient age, diagnosis, prior treatment, documentation requirements.

Step 3

Record Analysis

Ingest medical records, prior authorizations and visit notes. Map each document to the relevant criteria and extract supporting evidence.

Step 4

Gap Identification

Generate a structured evaluation: each criterion, met or not met and the specific evidence used. Gaps are flagged with what's needed.

Support

Appeal & Prevent

Met criteria become the foundation for a targeted appeal. Unmet criteria tell you what to fix before the claim goes out.

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Validate your documentation against payer criteria to respond with evidence not guesswork

Step 1

Pre-procedure validation

Confirm documentation meets criteria

Flag gaps while there's still time to adjust

Reduce denials at the source

Step 2

Payer policy intelligence

Parse policies from all payers

Criteria structured by procedure & more

Automatically updated as policies change

Step 3

Evidence-based support

Each criterion mapped to evidence

Feeds directly into the Appeals Agent

Targeted appealsinstead of generic cover letters

Coverage across major payers

Policies ingested from Aetna, UHC, BCBS, Cigna and regional plans. Currently live in behavioral health and orthopedics with more specialties added continuously.

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FAQ

What types of policies does the agent support?

Medical necessity policies, LCD/NCD documents and coverage determinations from major national payers and regional plans.

Can it validate before a procedure?

Yes. Run the evaluation pre-procedure to confirm documentation meets criteria before submission.

What does the output look like?

A structured report: clinical scenario, each criterion, met/not met and the specific evidence from your documentation.

How does this connect to appeals?

The evaluation feeds directly into the Appeals Agent as the foundation for targeted, evidence-based appeal packages.

What specialties are supported?

Live in behavioral health and orthopedics. The framework handles any specialty with payer-defined medical necessity criteria.

How long does setup take?

We calibrate with your clinical team on each policy. Most teams are evaluating claims within the first week.

Does it integrate with my EHR?

Yes. The agent pulls documents from your EHR and pushes results into your system of record.

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Need tailored automation?

Our AI engineers embed with your team to build & automate pipelines

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Enterprise-grade AI that actually works and gets smarter at scale

Full Audit Trail

Complete visibility into every agent action with screenshots and video recordings. Know exactly what happened, when and why.

Human-in-the-Loop

When our agent is uncertain, it escalates to your team for verification. These cases get logged and learned from, so they rarely happen twice.

Predictive Insights

Track payer trends, denial patterns and agent performance across your entire revenue cycle. Surface the signals that matter across your entire AR.

Security first, from the ground-up

End-to-end encryption protects sensitive data in transit and at rest, ensuring complete confidentiality.

Zero-trust architecture verifies every request, reducing attack surfaces and preventing unauthorized access.

Regular security audits and compliance checks keep our infrastructure resilient against evolving threats.

Granular access controls allow precise permission management, securing data at every level of the system.

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HIPAA

SOC2

Payer Policy Review ingests guidelines, extracts criteria & validates records

Put your revenue cycle on Autopilot