Quick answer:
Medical necessity appeals automation retrieves clinical documentation, matches payer medical policy, and submits appeals when care meets coverage criteria. Substrate's Payer Policy Agent evaluates encounters against payer rules and automates medical records appeals for behavioral health and specialty practices. This reduces biller research time on CO-50 and medical necessity denials.
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.
Payers deny claims when documentation does not demonstrate medical necessity for the billed service. Automation retrieves clinical notes, compares them to payer policy, and files appeals when documentation supports coverage.
Software that identifies medical necessity denials, retrieves clinical documentation, validates against payer coverage policies, and submits appeals without manual biller research on each case.
Substrate's Payer Policy Agent retrieves payer medical policies for the encounter, compares clinical documentation to policy requirements, and flags whether an appeal is supported before submission.
A payer determination that billed services were not medically necessary under plan coverage, often coded CO-50 or similar. These denials require clinical documentation and policy alignment to overturn.
Yes. Substrate retrieves therapy notes and treatment plans, validates against payer behavioral health policies, and files appeals for psychotherapy and mental health codes.
The agent programmatically retrieves clinical documents, finds relevant payer policies for the encounter, and evaluates whether documentation supports medical necessity before building an appeal package.
Session notes, treatment plans, prior authorizations, lab results, and operative reports depending on specialty. Substrate pulls from EHR systems via integrated connections.
Prior auth tools focus on pre-service approval. Medical necessity appeals automation handles post-denial recovery when claims pend or deny for insufficient documentation after service.
Commercial payers including Aetna, UHC, Cigna, and BCBS plans frequently request additional documentation for behavioral health, imaging, and specialty procedures.
Yes. Substrate evaluates documentation against payer-specific medical policy criteria and surfaces gaps before filing or escalates to clinical staff when documentation is insufficient.
Cohere Health focuses on prior authorization and utilization management workflows. Substrate automates post-denial appeals retrieval, policy review, and portal submission for denied claims.
No. Automation handles research, retrieval, and filing. Clinical staff review cases where documentation genuinely does not meet payer criteria or complex medical judgment is required.
Health systems deploy appeals agents integrated with Epic or other EHRs to batch-process medical necessity denials across service lines, reducing manual chart pulls and portal submissions.