SOLUTION · HEALTHCARE

Your revenue cycle,
run autonomously.

from $0.99 per resolved claim From charge capture to cleared payment — coding, submission, denial management, appeals, reconciliation — without a billing team in the loop.

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Revenue cycle management is broken by design.

The average US health system denies 5–15% of claims on first submission. More than half are overturned on appeal — meaning the revenue was always recoverable, but recovery required human time most billing departments do not have. Appeals windows are strict: most payers require appeals within 30–180 days. Missed windows mean permanent revenue loss.

Coding errors cause most initial denials. A single mismatched ICD-10 diagnosis and CPT procedure code, a missing modifier, or an out-of-network authorisation gap is enough to trigger a denial that costs more to appeal than it returns at low claim values. The result is systematic write-off of recoverable revenue.

Nine steps. No billing staff required.

Every step below is executed autonomously by the PLRX RCM agent fleet. The PLRX Durable State Machine persists state across all of them — a claim that enters a denial management workflow and requires a peer-to-peer review scheduled four weeks out remains in exactly the right state, with full claim context, when the review date arrives.

  1. 01
    Charge Capture Ingest
    Encounter data arrives from the EHR or practice management system via structured payload. The Patient Access Representative agent records the inbound event, persists the encounter record, and starts a PLRX Durable State Machine workflow. Every field is logged. Every subsequent state transition is appended to the durable event log. Mission state: ENCOUNTER_RECEIVED.
    encounter ingestPLRX DSM workflow startedevent logged
  2. 02
    Eligibility Verification
    The Patient Access Representative agent submits an EDI 270 eligibility request to the patient's payer via the clearinghouse. The EDI 271 response confirms active coverage, effective dates, deductible status, and co-pay requirements. If coverage is inactive or the patient is enrolled in a plan that requires a different billing pathway, the workflow branches immediately — the claim is not submitted to a payer that will not cover it.
    EDI 270/271eligibility verificationcoverage confirmation
  3. 03
    Medical Coding Validation
    The Medical Coder agent validates all ICD-10 diagnosis codes, CPT procedure codes, and HCPCS codes on the encounter. NCCI (National Correct Coding Initiative) edit checks are applied — code pairs that cannot be billed together on the same date of service are flagged before the claim is built. LCD (Local Coverage Determination) and NCD (National Coverage Determination) rules are checked against the patient's payer and diagnosis. A Levenshtein-distance algorithm auto-corrects common ICD-10 transcription errors. Encounters with unresolvable coding conflicts surface a correction request to the billing team and suspend durably — input_required — until resolved.
    ICD-10 validationCPT / HCPCSNCCI editsLCD / NCDLevenshtein algo
  4. 04
    Claim Construction & Submission
    The Claims Submission Specialist agent builds a fully compliant HIPAA 5010 EDI 837P (professional) or 837I (institutional) transaction from the validated encounter data. Payer-specific billing rules — modifier requirements, place-of-service codes, taxonomy codes, referring provider requirements — are applied before the claim is sealed. The claim is submitted to the clearinghouse for payer routing. The agent tracks the EDI 277 claim status acknowledgement and logs the payer-assigned claim control number.
    EDI 837P / 837IHIPAA 5010clearinghouse routingEDI 277 tracking
  5. 05
    Claim Status Monitoring
    The Claims Submission Specialist agent polls payer status endpoints at configured intervals using EDI 277 queries. Claims that enter a payer's adjudication queue are tracked through to a final status: paid, partially paid, or denied. The PLRX Durable State Machine suspends the workflow at each polling interval without consuming resources during the wait — a claim under adjudication for 45 days holds its full context without any active processing overhead.
    EDI 277 queriesadjudication trackingdurable polling
  6. 06
    Denial Analysis & Classification
    When a denial arrives, the Denial Management Specialist agent parses the denial reason codes from the EDI 835 or claim status response — CO (contractual obligation), PR (patient responsibility), OA (other adjustment), and their sub-codes. Each denial is classified by root cause: coding error, missing modifier, authorization issue, timely filing, duplicate claim, or medical necessity. The classification drives automatic routing: correctable denials go directly to the Claims Submission Specialist for resubmission; complex denials requiring clinical documentation go to the Appeals Specialist.
    CO / PR / OA codesroot cause classificationA2A routing
  7. 07
    Appeals Preparation & Submission
    The Appeals Specialist agent prepares a structured appeal package — appeal letter, clinical documentation summary, coding rationale, and supporting regulatory citations — using Claude Sonnet / Opus for nuanced clinical interpretation and argument construction. Appeals deadlines are tracked from the denial date and enforced by the PLRX Durable State Machine. The agent submits the appeal via the payer's portal or fax workflow, tracks the appeal status, and escalates to a peer-to-peer review request if the initial appeal is upheld. The workflow suspends durably through the review scheduling period — often weeks — and resumes on the review date.
    appeal letter generationdeadline enforcementpeer-to-peer requestClaude Sonnet / Opus
  8. 08
    Payment Posting & Reconciliation
    When an EDI 835 remittance advice arrives, the Payment Reconciliation Specialist agent parses every line — patient-level and claim-level adjustments, allowed amounts, contractual adjustments, and payer-applied reason codes. Each payment is reconciled against the original claim and the provider's contracted rate. Underpayments — where the payer paid less than the contracted rate — are flagged automatically and routed to the Appeals Specialist. Correct payments are posted. Patient responsibility balances are identified and sent to the patient billing workflow.
    EDI 835 parsingcontracted rate reconciliationunderpayment detectionpatient balance routing
  9. 09
    Mission Complete
    The PLRX Durable State Machine transitions to CLAIM_RESOLVED. The mission record captures the full lifecycle: encounter ingest, coding validation, claim submission, denial events, appeal outcomes, and final payment. All AI prompts, all EDI transactions, and all state transitions are logged in the WORM audit trail. A claim resolved through multiple denial-appeal cycles — completing in 90 days — is billed as a single settled outcome.
    CLAIM_RESOLVEDWORM audit logsingle billed outcome

Six specialists.
Full cycle coverage.

Six agents cover every domain of the revenue cycle — from eligibility at intake through payment reconciliation at close. The Patient Access Representative orchestrates the full lifecycle, delegating to each specialist via A2A at the appropriate workflow stage. Specialists execute in parallel where the workflow permits: coding validation and prior authorization checks run simultaneously for services that require both.

The Denial Management Specialist and Appeals Specialist work in a closed loop — denials classified as appealable are handed off via A2A immediately, without a human making a routing decision. The Payment Reconciliation Specialist closes the loop, posting payments and flagging underpayments back to the Appeals Specialist for recovery.

Every denial classified
in minutes. Not days.

When a claim is denied, the Denial Management Specialist agent parses the reason codes from the payer response and classifies the denial by root cause in real time. The classification is not a guess — it is a deterministic rule engine that maps denial codes to action categories, which then drive A2A task delegation to the right specialist agent. No human reads a remittance file to decide what to do next.

Correctable denials — wrong modifier, missing occurrence code, NCCI bundle violation — are rerouted to the Claims Submission Specialist for corrected claim submission within minutes of the denial arriving. Complex denials requiring clinical argument go to the Appeals Specialist for structured appeal preparation. Appeals deadlines are enforced by the PLRX Durable State Machine — the workflow does not forget a deadline, even if the denial sat unprocessed for three weeks in a paper queue at the previous organization.

COMMON DENIAL CODES · AUTOMATED RESPONSES
  • CO-4
    Service inconsistent with modifier — code combination fails NCCI edit
    → Medical Coder reviews modifier · corrected claim submitted
  • CO-16
    Claim lacks information required for adjudication
    → Claims Submission Specialist identifies missing field · resubmits with correction
  • CO-29
    Timely filing limit expired for this payer
    → Appeals Specialist prepares timely filing exception with documentation
  • CO-97
    Payment included in allowance for another service
    → Denial Management reviews bundling logic · unbundling appeal if justified
  • CO-109
    Service not covered by this payer — coordination of benefits issue
    → Patient Access Representative verifies COB order · routes to correct primary
  • PR-1
    Deductible amount — patient financial responsibility
    → Payment Reconciliation posts patient balance · patient billing workflow initiated

A claim that never gets lost.

The claim lifecycle spans weeks to months — adjudication, denial, appeal, peer-to-peer review, resubmission, payment. Every stage is a durable workflow state. A claim that enters a denial loop at week three and requires a scheduled peer-to-peer review four weeks out holds its full context — encounter data, all prior EDI transactions, denial reason codes, appeal documentation — and resumes exactly when needed. Nothing is lost. No manual re-entry required.

Pay when the claim resolves.
Not while it works.

From $0.99
per resolved claim outcome
See full pricing detail →

A resolved claim outcome is one that reaches a final state — paid, appealed and paid, or written off — after passing through the agent workflow. You are not billed for claim processing time, for appeal cycles, for denial loops, or for the duration of adjudication waits.

A claim that takes three appeal cycles over 90 days to resolve counts as a single outcome. A claim that is submitted, denied, appealed, and then paid on the second appeal is one billing event. Volume pricing is available for high-throughput RCM deployments.

  • Resolved to payment — billed once per claim
  • Multi-cycle appeals counted as single outcome
  • No charge for adjudication wait time
  • Timely filing failures not billed
  • No charge for EDI transaction volume
  • No setup fees · No monthly minimums

Your revenue cycle, running autonomously.

Connect your charge capture system and watch the RCM fleet process a real claim — coding validation to payment posting — in a live session.

Request a demo and we will walk you through the full denial-to-appeal loop.

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