RCM Director · Revenue Cycle Management

What RCM looks like
when the agents
run the cycle.

Revenue cycle management involves a defined sequence of steps — eligibility verification, prior auth, claims scrubbing, submission, denial management, AR follow-up — each with documented rules, payer-specific requirements, and a measurable outcome. The process is defined. The execution is manual.
Every step in the revenue cycle where a human absorbs the execution is a step that adds days to resolution, creates variability in quality, and scales only by hiring. Autonomous RCM means the agents execute every standard step — your RCM team handles the exceptions that require their judgment.
94% of PLRX missions in healthcare operations resolve without a human touchpoint. That number reflects a live production rate — not a roadmap target — running against real payers, real providers, and real patients.

94% autonomous resolutionFrom $0.99 per missionEnterprise Agentic

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See autonomous RCM.

Tell us which part of your revenue cycle carries the most manual friction. Proof of concept in 2–3 weeks — production in 12 weeks.

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The Revenue Cycle — What Agents Run End to End

Each stage of the revenue cycle has a defined rule set and a measurable outcome. These are the stages where PLRX specialist agents operate — running continuously, handling standard workflow types without staff involvement.

Stage 01 · Pre-Submission

Eligibility verification, prior auth, and documentation — before anything reaches the payer

EDI 270/271 eligibility verification before every claim submission. EDI 278 prior authorization with clinical documentation collection, payer portal monitoring, pend response handling, and resubmission. Claims scrubbing against current NCCI edits, modifier requirements, and payer-specific rules. Every claim reaches the clearinghouse validated and complete. First-pass rejection rate for agent-scrubbed claims: below 5%.

Stage 02 · Submission and Monitoring

Real-time payer portal monitoring — no submission goes unwatched

Continuous monitoring of payer portals and clearinghouse queues across all payers simultaneously. Every response — approval, pend, denial, request for information — acted on the moment it arrives. Nothing waits because nobody logged in to check. Prior auth pend responses resubmitted the same day with the required documentation. Payer response lag: eliminated.

Stage 03 · Denial Management

Denial queue worked continuously — standard types resolved same day

Denial reason codes read and classified on receipt. Standard denial types — CO-4 modifier errors, CO-18 duplicates, CO-27 eligibility — corrected and resubmitted same day without biller involvement. Medical necessity denials: appeal package assembled and submitted within 24–48 hours. Timely filing monitoring: claims approaching appeal windows surfaced for priority handling before the window closes.

Stage 04 · AR Follow-Up

Aged AR monitored continuously — no revenue ages past timely filing

Every open claim monitored against its payer-specific timely filing window. Follow-up initiated at day 60. Escalation to the billing team at day 75 with specific status, days remaining, and recommended action. Claims in the aged AR queue identified as denied but unworked: entered into the denial management workflow immediately. Timely filing losses for monitored claims: eliminated.

RCM Agent Use Cases — What Runs Autonomously vs What Escalates

What autonomous RCM
looks like in production.

RCM Stage	What Agents Handle Autonomously	What Escalates to Your Team
Eligibility verification	EDI 270/271 checks before every submission. Coverage gap identification. Alternative coverage search. Eligibility confirmation logged in the workflow.	Complex coverage scenarios requiring clinical review. Coverage disputes requiring payer contact by a billing specialist.
Prior authorization	Submission, payer portal monitoring, pend response handling, documentation collection and resubmission, approval notification. Standard auth types end to end.	Clinical documentation that requires physician review before submission. Denials requiring clinical appeal with physician attestation. Unusual payer responses outside defined resolution authority.
Claims scrubbing	NCCI edit validation, modifier correction, diagnosis code specificity checks, payer-specific rule application. Standard error types corrected before submission.	Complex coding scenarios requiring coder judgment. Payer rule changes not yet encoded in the agent ruleset. Ambiguous modifier situations requiring clinical input.
Denial management	Standard denial types corrected and resubmitted same day. Appeal packages assembled for medical necessity denials. Timely filing monitoring and escalation.	Denials requiring clinical attestation. Complex payer negotiations. Denials outside standard appeal authority. Cases requiring external audit review.
AR follow-up	Continuous monitoring, follow-up at day 60, escalation at day 75. Payer portal status checks. Identification of denied-but-unworked claims in the aged queue.	Claims approaching timely filing with complex resolution requirements. Payer disputes requiring account manager involvement. Write-off decisions requiring RCM Director review.

Revenue Cycle · The Compliance Question That Determines Deployment Approval

Who can see what the agent did?

When an AI agent submits a claim, works a denial, or initiates an appeal on your behalf, the compliance record must show exactly what was done, when, and under what authority. If a payer audits a submission, a patient disputes a claim, or a compliance review asks for the full action record for a billing period — that record must exist without reconstruction.

PLRX logs every agent action on every RCM workflow in real time. Every eligibility check run, every prior auth submitted, every denial code read, every correction applied, every resubmission made — captured in a structured, timestamped WORM record. Queryable by claim number, by payer, by denial code, by date range, or by workflow type.

The record distinguishes between what the agent handled autonomously and what it escalated to your team. Both are logged with equal completeness. If a payer questions whether a timely filing follow-up was initiated, the PLRX audit trail shows the date, the action taken, and the result — without depending on biller recall or email history.