Architecture Overview
One platform. Two layers.
PayPredict identifies and prioritizes denials that matter, while Recovr AI takes autonomous action to get you paid. No handoffs. No delays. No revenue left behind.
Operational Modes
Full Autonomy
AI-driven end-to-end recovery. Recovr AI identifies denials and drafts clinical appeals automatically, ensuring no claim falls through the cracks.
- 100% attention to recoverable denials
- Zero manual handoffs or delays
- Real-time payer policy research
Human-in-the-Loop
Automatic process with human approval. Our platform drafts claim chaim changes but waits for human approval before submission maintaining full audit control.
- 90-100% of work performed by agents
- Human approval for sending claims
- Full audit trail for every action
Fully Manual
Complete human control. For complex cases, our research assistant provides deep-dive data and clinical insights to guide manual decision-making.
- Deep clinical research support
- Full human decision authority
- Customizable workflow paths
The Agent's Toolbox
Recovr AI is not a dashboard with a chat window — it is an agent with dozens of tools. On every denial it decides whic htools to call: tools to look things up, or tools to take action.
examples of information tools
01
Payer Portal Verification
Automated site visits to check claim status and eligibility directly at the source.
02
Policy Research
Cross-referencing denials against specific payer medical policies and LCD/NCD rules.
03
Coding Auditor
Analysis of CPT, ICD-10, and HCPCS code compatibility for accurate billing verification.
04
Contractual Review
Validating payer payments against specific provider contract terms and fee schedules.
05
Clinical Look-up
Retrieving relevant patient records and clinical documentation for appeal support.
06
Previous Remittance
Reviewing historical payment patterns for the same codes and payer combinations.
07
Prior Auth Check
Confirming existence and validity of necessary authorizations prior to services.
08
Benefit Search
Instant verification of specific patient benefits and coverage limitations.
09
Payer Rules Engine
Accessing a logic repository of thousands of payer-specific denial codes and justifications.
10
Credentialing Status
Checking the enrollment status of providers for specific payers to avoid coverage gaps.
11
EDI Reconciliation
Matching batch files against individual claim responses to trace missing revenue.
12
Payer Escalation Log
Monitoring and retrieving data from previous interactions with payer representatives.
examples of action tools
01
Appeal Submission
Drafts and submits appeals to payer portals with clinical justification and supporting attachments.
02
Corrected Claim Filing
Identifies field-level corrections, validates the claim — including confirming the destination payer can receive it — and submits the replacement.
03
Reconsideration Tickets
Creates payer reconsideration tickets with reason codes, disputed amounts, and attachments, filed directly through the Optum API.
04
Document Analysis
Reads payer PDFs and images with vision-capable AI and folds them into the analysis.
05
Document Upload
Attaches supporting documentation to existing payer tickets — no portal session required.
06
Letter Generation
Appeal and information-request letters, drafted for human review and exported as PDF for mail or fax.
Every tool call is logged with timestamp and attribution — the audit trail behind every recommendation.
Onboarding Process
Day 0
48 Hours
Week 2
File Submission
Live Deployment
Optimization
Upload your standard EDI 835/837 files. No EHR or PMS integration required. Our system begins processing your data immediately.
Within 48 hours, your closed-loop platform is live. PayPredict identifies denials, and Recovr AI takes autonomous action to recover revenue.
Refine your automation level and tuning parameters. We ensure your system is optimized for your specific clinical and billing workflows.