Quick answer:
Appeals automation uses AI to detect denials, retrieve documentation from the EHR, validate against payer requirements, file appeals through payer portals, and monitor until payment. Substrate resolves 40%+ of medical records appeals handsfree with full video audit trails. This differs from denial prevention tools that flag issues before submission.
Inclusion criteria:
Guides and FAQs in this topic, plus the Substrate product that executes the workflow.
Honest limitations: Substrate does not replace a clearinghouse, EHR, or full-cycle BPO. It automates post-submission AR (status, appeals, posting, eligibility) and still routes clinical edge cases to staff. Coding, CDI, and patient-facing billing are out of scope.
After a claim denies, appeals automation retrieves records, builds payer-specific submissions, and tracks outcomes. Recovery-focused automation delivers faster ROI on dollars already trapped in AR than prevention-only tools alone.
Yes. Substrate detects medical records and eligibility denials, pulls documentation from the EHR, validates completeness, and submits through payer portals with video audit trails.
End-to-end appeal handling without a biller manually retrieving records, logging into portals, or tracking follow-up. Substrate monitors pended claims and auto-submits correct documentation.
Substrate handles medical records (CO-16), eligibility, and medical necessity denials across major commercial payers. Prior authorization appeals are expanding.
Yes. Substrate connects to 24+ EHR and PM systems to download session notes, treatment plans, prior authorizations, and supporting clinical documentation.
Agents log into payer appeal portals, attach retrieved documents, submit appeals, and capture confirmation references. Every step is recorded for compliance review.
Substrate customers report 40%+ recovery on medical records appeals and significant net revenue lift. Heading Health eliminated manual AR follow-up on RFIs.
Yes. Substrate validates coverage against eligibility responses and submits corrected documentation or corrected claim data through payer workflows.
Denial management often focuses on analytics and prevention. Appeals automation executes recovery: retrieving records, filing, and monitoring until payment on denied dollars.
EHR integration accelerates record retrieval but Substrate supports multiple connection methods. Most practices integrate via API, HL7/FHIR, or PM export within days.
Timelines vary by payer. Substrate monitors appeal status continuously and escalates stalled appeals. Many medical records appeals resolve in days rather than weeks of manual follow-up.
Aetna, UHC, Cigna, and multiple BCBS plans among 3,500+ covered payers. Substrate expands appeal routes as payer portals allow programmatic submission.
Yes. After filing, Substrate tracks payer responses and payment posting, routing unresolved cases for human review only when genuinely uncertain.