The medical records denial workflow
Medical records denials (CO-50, lack of medical necessity) require supporting clinical documentation that billers must pull from the EHR, match to the correct encounter, and submit through payer portals. Manual teams spend 15 to 45 minutes per appeal and often use generic cover letters that do not reference payer-specific criteria.
Step 1: Detect the denial
The Claim Status Agent surfaces under-paid or denied claims with explicit or implicit medical records denial reasons. It can also utilize your SOPs to detect specific patterns that you know about in your practice. Appealable claims route directly to the Appeals Agent without manual queue triage.
Step 2: Retrieve records from EHR
The agent logs into your EHR, navigates to the correct encounter, and downloads operative reports, visit notes, prior authorizations, imaging results, and referral documentation specific to that date of service.
Step 3: Validate documentation
Document Review categorizes each file, confirms patient and date of service alignment, and verifies authorization windows. The Policy Agent evaluates medical necessity criteria against what is documented in the record.
Step 4: Build and file the appeal
An appeal letter references specific payer policy criteria and points to attached documentation satisfying each requirement. The agent navigates the payer portal, uploads the package, and captures reference numbers with screenshots and video.
Step 5: Monitor until paid
Post-filing, the agent checks claim status via EDI, portal agents, and EOB retrieval until the appeal is adjudicated and payment is confirmed.
Manual vs automated medical records appeals
Related product
See live specialties and payers on the Appeals Agent product page.