Read remittance advice, classify why each claim denied, assemble the appeal with its supporting record and work aged AR by payer — with deadline tracking, audit trails and a person signing every appeal and write-off.
Ingest remittance and denial lines from the 835, the payer portal or a paper EOB, against the claim as submitted.
02
Pull the open balance, the claim and payment history, and any appeal already filed on the same claim.
Reason
03
Read the group code, reason code and remark code together, and translate them into the cause the payer is asserting.
04
Check that cause against the payer's own policy, the contract terms and the window that applies at each appeal level.
05
Retrieve the order, note, authorisation and coding detail that would support the claim, and mark what is missing.
Decide
06
Separate a corrected claim from an appeal, and mark the medical-necessity ones for a physician advisor.
07
Hold a claim whose window is closing, whose evidence is thin, or whose balance would move to the patient.
Out
08
Draft the packet — the letter, the level it is filed at and the record extract that supports it — for a named person to sign.
09
Retain the denial line, the classification, the evidence attached, the deadline and every reviewer correction.
→Product statement
The agent classifies, drafts and chases. Signing an appeal, approving a write-off and changing what a patient owes stay with a person.
Example workflow
One denial, end to end
AgentHuman
1Remittance received835 file, payer portal or paper EOB, matched to the claim as it was submitted
2Denial line readGroup code, reason and remark codes, the adjustment amount and the line it lands on
3Root cause classifiedWhat the payer is asserting, read against its own policy and your contract terms
4Remedy and evidence assembledCorrected claim, appeal or hold; the level and deadline calculated; the supporting record pulled
No human action required
Stages 1 to 4 run without a person in the loop — reading, classifying and evidence-gathering finish before anyone is asked to look. A claim near its filing window ends that stretch early.
5DecisionSplits on classification confidence and what is at stake
Clear reason, evidence complete
Packet drafted and queued for signature.
Ambiguous reason or thin evidence
Goes to a specialist before anything is drafted.
Denials specialist
Reads the denial line, the proposed cause, the evidence pulled and the deadline, then signs — a physician advisor signs the medical-necessity ones.
Sign and file · Correct · Escalate
Signed — handed back▼
6Packet filed and AR workedOnly where write access and approval policy allow it; the appeal carries a person's signature
7Outcome evaluatedClassification accuracy, appeal outcome, deadline adherence and sampled write-offs by payer
Corrections
Root causes a reviewer re-classifies are counted in the evaluation.
What should not run autonomously
Human approval stays in control
Outside the boundary — human approval required8 items
Signing or filing an appeal.
Approving a write-off or a contractual adjustment.
Posting an adjustment to a patient's balance.
Deciding a denial is not worth appealing.
Automation boundaryAgent acts unaided
✓Read the remittance line and classify what the payer is actually asserting.
✓Calculate the appeal level, the filing route and the window that applies.
✓Assemble the appeal packet and the record extract that supports the claim.
✓Work aged AR by payer and hold near-deadline and disputed accounts for review.
Write actions run only inside the approval boundaries agreed during implementation. A patient's balance is not one of them.
Judging medical necessity or level of care.
Moving a balance to statements or collections.
Releasing records beyond what the appeal needs.
Changing appeal templates, deadline rules or write-off thresholds.
Example output
One denial line, annotated
Everything the agent proposes is attached to the remittance line it came from.
Denial output · single remittance lineIllustrative example
Claim
Filing window
Denial line
Root cause
Confidence
Proposed remedy
Outpatient infusion, one line
Level 1, 41 days left
CO-50, N115
Medical necessity (LCD)
88%
Appeal, not a corrected claim
As receivedThe remittance line, the claim it posted against and the window the payer's own notice opens — nothing on this side is inferred.
Evidence usedPayer coverage policyOrder and clinical notePrior claim history
Why an appeal, not a resubmissionThe payer is disputing coverage, not how the claim was built. A corrected claim would come back a duplicate.
ActionSign and fileCorrectEscalate
What the score decidesBelow the threshold the denial goes to a specialist before anything is drafted. A person signs on either path.
Value
Where AI adds value
The same four claims, placed at the point in the workflow where each one applies.
Where the value landsValue 01 – 04
Every denied and unpaid claimFrom the 835, the portal or the EOB
03Classification & evidence
Apply the payer's own rules
Use that payer's published policy, your contract terms, the appeal levels it actually runs and the window each one carries.
01Approved path
Take the reading and keying off the AR team
Remittance lines are read, classified and matched to a remedy before anyone opens the account.
02Human review
Work the queue by deadline and value
Ambiguous reasons, thin evidence and closing windows reach a specialist early, instead of the queue draining toward whatever closes fastest.
04Build an evidence trail
Retain the denial line, the classification, the policy read, the evidence attached, the deadline and the reviewer's correction — on both paths.
Integrations
Typical integrations
Five system groups connect to the same agent. Which of them are in scope is decided in discovery.
Aggregate classification quality can look acceptable while two or three payer and denial-type cohorts carry most of the misclassification, most of the reviewer corrections and nearly all of the deadline risk. Nestack reports performance by slice, not only in total.
Slice performance — reported separately, not only in aggregateIllustrative example
Slice
Failure rate
Lift
Lift vs. threshold
Status
Medical-necessity denials
5.1%
3.4×
Review
Medicare Advantage post-acute
4.2%
2.8×
Review
Medicaid and dual-eligible accounts
2.9%
1.9×
Watch
Routine contractual adjustments
1.0%
0.7×
Normal
Bar: lift vs. contractual-adjustment baseline · scale 0–4.0× · tick marks the 2.0× review threshold2 of 4 slices over threshold
Evidence-linked improvement
Working the same denial twice means nothing went upstream
A recovered claim is not a closed case. Where the cause sat in registration, authorisation or coding, the fix belongs there — and with that team.
Improvement cycle · five stagesSwitchback — the path turns at Improve and returns at Learn
01Detect
Misclassification, corrections or days-to-file move in a payer slice.
02Diagnose
Traced to the code read, the policy version, the deadline rule or the remedy chosen.
03Improve
The code mapping, deadline rule or evidence template is re-approved and version-linked.
04Verify
Re-run against held-out remittances from that payer, including the ones that failed.
05Learn
That denial becomes a regression case and, where preventable, a front-end change request.
Learn → DetectThe return edge. A preventable denial is handed to registration, authorisation or coding — not absorbed by the AR team.
Typical build scope
Twelve workstreams across six weeks
The build scope read against the delivery timeline. Week structure follows the six-week plan — discovery, remittance, classification and evidence, evaluation, integration, then production validation and handover.
WorkstreamWeek 1Week 2Week 3Week 4Week 5Week 6
01Workflow discovery and automation-boundary definition.
02Clearinghouse and patient-accounting access.
03Payer matrix: appeal levels and deadlines.
04Remittance ingestion and normalisation.
05Root-cause classification and remedy routing.
06Deadline and duplicate-filing guards.
07Evidence retrieval and disclosure scope.
08Appeal-packet drafting and signature workflow.
09Write-off and adjustment approval controls.
10Payer-slice evaluation and regression cases.
11AR worklist, filing and posting write-back.
12Observability, deployment and Agent Care handover.
12 workstreams · 6 weeks · bar shows the weeks a workstream is active — several run in parallelFinal scope and sequence confirmed in discovery
Engagement tiers
What each tier includes
Rows are the capabilities named in each tier's scope. Higher tiers include everything below them.
Capability✓ in scope · — not at this tierPilotOne payer, one denial typeProductionProduction AR integrationAdvancedMulti-payer / multi-facility
Introduced at Pilot
Denial root-cause classification✓✓✓
Deadline and duplicate guardrails✓✓✓
Minimum-necessary disclosure scope✓✓✓
Appeal and write-off signed by a person✓✓✓
Baseline evaluation✓✓✓
Introduced at Production
Payer matrix and policy retrieval—✓✓
Appeal-packet drafting with evidence—✓✓
AR worklist, write-back after approval—✓✓
Observability and evaluation—✓✓
Introduced at Advanced
Multi-payer and multi-facility——✓
Enterprise controls and audit reporting——✓
Build priceFrom $5,000From $8,000Custom quote
Final build priceConfirmed after discovery based on payer mix, clearinghouse and patient-accounting integrations, denial volume, appeal routes, approval controls and deployment requirements.
Separate from buildBuild pricing is separate from recurring Agent Care, which covers managed monitoring, evaluations, incidents and verified improvements after launch.
What we need from you
What you bring, and what we build with it
Each input maps to a piece of build scope and a week in the delivery timeline.
You bringWe build with it
01Your payer matrix — appeal levels, routes and deadlines→Payer matrix: appeal levels, deadlines and filing routesWeek 1
02A representative sample of remittance files and denied claims→Remittance ingestion, denial-line normalisation and the classification baselineWeek 2
03Access to patient accounting, the clearinghouse and payer portals→Epic Resolute, clearinghouse 835/837 and payer-portal integrationWeek 2
04Minimum-necessary and release-of-information rules→Evidence retrieval scope, redaction and disclosure loggingWeek 3
05Your write-off, adjustment and patient-billing policy→Write-off and patient-adjustment approval controlsWeek 4
06Appeals you lost, and the ones you should have filed→Evaluation suite, regression cases and failure-mode testingWeek 4
07Named denials specialists and a physician advisor→Signature workflow, then pilot filings and production validationWeeks 5–6
Nothing else is requiredDeployment, documentation and Agent Care handover are ours.
Delivery timeline
Four phases across six weeks
Phases are drawn over the weeks they actually occupy. Week 5 carries both the payer-slice evaluation and the first supervised filings.
PhaseW1W2W3W4W5W6
DiscoveryW1
BuildW2 – W3
EvaluateW4 – W5
Pilot & LaunchW5 – W6
Week focusW1Payer matrix mapped: appeal levels, routes and deadlinesW2Remittance ingestion and the denial-classification baselineW3Remedy routing, deadline rules and evidence retrieval scopeW4Evaluation suite, write-off controls and failure-mode testingW5AR worklist integration, supervised filings and correctionsW6A full appeal cycle filed under signature, then Agent Care starts
Reading the bandWeek 5 carries two bars: the first supervised filings are what the evaluation suite is run against, not something that follows it.
At the end of W6A full appeal cycle has been drafted, signed and filed under supervision, then Agent Care takes over monitoring.
DurationSix-week plan shown · typical delivery 4–6 weeks depending on scope confirmed in discovery.
Next step · Healthcare AI agent
Build a denials agent around the way your AR team already works.
Show us a month of remittance, your payer matrix and how a write-off gets approved today. We'll classify that month's denials against the causes you already track, then agree what a person signs before anything is filed.
