The full path, patient to paid claim.
One platform spanning the patient-to-claim workflow, and across every layer, AI recommends while a certified coder confirms before anything bills.
Clinical AI Layer
- Automated chart understanding
- Clinical entity extraction
- Diagnosis & procedure mapping
Coding Intelligence
- ICD-10 auto-suggestion
- CPT / HCPCS recommendation
- Modifier validation
- HCC capture support
Revenue Integrity Engine
- Denial prediction
- Under-coding detection
- Missed-procedure identification
- Medical-necessity validation
Compliance Monitor
- Documentation-gap analysis
- Audit-readiness scoring
- CMS & payer-rule validation
Patient Access
- Registration & scheduling
- Real-time eligibility
- Insurance & benefits validation
- Prior auth & copay estimation
Watch a note become a claim.
AI does the first pass at speed; certified coders review what matters; you approve before anything goes to the payer. Nothing autonomous touches your revenue without a human in the loop.
Capture
ClaimPrism AI reads the visit note from your EHR, the documentation you already create, no new workflow for clinicians.
AI codes
The model proposes CPT, ICD-10, HCPCS, and modifiers, flags under-capture, and checks each line against payer rules.
Expert reviews
Certified coders review flagged and high-value charts, the human-in-the-loop step that keeps coding accurate and defensible.
You approve & submit
You see what changed and why, approve, and submit a clean claim, with a full audit trail attached to every code.
Plugs into what you already run.
ClaimPrism AI fits the way your organization already runs, ambulatory or hospital-based, reading the notes your providers write, and coding each claim to CMS, NCCI, and the rules of the payer you're billing. No rip-and-replace, no new workflow. Each EHR/PM and payer integration is built and validated for the systems you run.
01. Customized
EHR integration
ClaimPrism AI is compatible with the EHR, practice-management, and hospital information systems urgent care, ambulatory, and hospital teams already run, including Epic, Oracle Health (Cerner), athenahealth, eClinicalWorks, NextGen, Meditech, Elation, Tebra, and Experity. We build and integrate to the system you use, customized to the documentation workflows your providers and HIM department already follow, professional (837P/CMS-1500) and facility (837I/UB-04) claim types alike, with no new systems to learn.
Once your integration is built and live, you keep a dedicated integration lead who re-tunes the model as payer and CMS rules change, annual ICD-10-CM/CPT/HCPCS updates land, and your team sends feedback from the floor.
ClaimPrismAI+ Meditech, MEDITECH Expanse, and any EHR / PM / HIS, we build to yours
02. Codes to every
major payer’s rules
Medicare (including MACs and LCDs), Medicaid, commercial, and occupational plans each carry their own coding logic, layered on top of CMS-wide rules like NCCI edits, Medically Unlikely Edits (MUEs), and National Coverage Determinations (NCDs). ClaimPrism AI is built to code each claim to the right payer’s requirements, and we configure and integrate the rules for the plans you actually bill, so claims land clean the first time.
Your model is kept current as payer policies, MAC-specific LCDs, and CMS rule changes land, so coding stays compliant across every plan you bill.
ClaimPrismAI+ State Medicaid MCOs, workers’ comp, and regional plans, we code to your payer mix
ClaimPrism AI is implemented for your environment, with each EHR/PM and payer integration built and validated for the systems you run. Product and company names shown are trademarks of their respective owners, listed for compatibility reference only and not implying endorsement, partnership, or an existing integration.
You keep seeing patients. We handle the build.
Getting started doesn't add work for your clinicians. We handle the integration with your existing EHR/PM environment and confirm the path before go-live.
Confirm fit
On your revenue check we review sample charts, estimate under-capture, and confirm your EHR/PM integration path.
Connect workflows
We set up the connection to your EHR and configure routing and payer rules to how your centers actually run.
Begin chart review
ClaimPrism AI starts reviewing visits, first 100 claims free for one designated center, and you see recovered revenue before you pay.
03. Real-time
revenue reporting
After go-live, your team gets one shared dashboard, recovered revenue, denial trends, clean-claim rate, and coding accuracy, broken down by location and coder.
A single source of truth your billing lead and your CFO can both act on, catch drift week by week, and stay audit-ready with defensible, payer-compliant scoring.
The AI drafts it. A human signs off.
ClaimPrism AI reviews 100% of your visits before billing, but nothing autonomous reaches a payer on its own. AI proposes the codes and flags under-capture; certified coders review what matters; you decide what happens next.
- You choose the routing. Auto-apply a confident code, send it back to the provider, or queue the chart for coder review.
- E/M at the highest defensible level. Coded to exactly what the documentation supports, never more, never less.
- Certified coder accountability. A trained human stands behind every code, with the documentation to back it.
Every payer plays by different rules. We know all of them.
ClaimPrism AI's model is trained on current coding guidelines and payer-specific policies, so every visit is coded accurately and in line with what that insurer actually requires, then confirmed by a certified coder. Cleaner claims, fewer denials, and revenue you can defend on audit.
Payer-specific rule checks
Commercial, Medicare, Medicaid, and occupational plans each carry their own logic. ClaimPrism AI codes to the right one, every time.
Under-capture recovery
Surfaces the separate E/M, modifier 25, POS 20, and HCPCS S-codes that fast walk-in workflows routinely miss.
Compliance-first, never over-reaching
Coded to exactly what the documentation supports, defensible on review, so accuracy never becomes audit risk.
Certified human confirmation
A certified coder signs off before a claim bills. The AI moves fast; a trained human stands behind the result.
Always current with the rules
Annual ICD-10-CM, CPT, and HCPCS Level II updates, NCCI/MUE edit changes, and new CMS transmittals are folded in as they land, so coding never drifts out of compliance.
Documentation-backed audit trail
Every code carries the documentation that supports it and a clear audit trail, so a payer review is a non-event, not a fire drill.
Why teams fire their coding vendor for us.
Manual coding, your EHR's built-in auto-coder, and audit-only vendors each cover part of the picture. ClaimPrism AI combines AI speed, certified human review, payer-rule alignment, and reporting in a single pre-bill workflow.
| Capability | ClaimPrism AIAI + certified review | Manual codingin-house / outsourced | EHR auto-codingbuilt-in | Audit-only servicesretrospective |
|---|---|---|---|---|
| Coding & revenue capture | ||||
| AI-assisted coding at urgent-care speed | , | , | ||
| E/M leveling validated against documentation | ||||
| Under-capture & dropped-modifier recovery (E/M +25, POS) | , | |||
| Acuity / down-coding checks (flags under-leveled visits) | , | |||
| Claims & payer compliance | ||||
| Payer-specific scrubbing before submission (CCI/NCCI, LCD) | , | |||
| Pre-bill, catches issues before claims go out | , | |||
| Denial tracking & recovery analytics | , | , | ||
| Human review & compliance | ||||
| Certified coder review (human-in-the-loop) | , | |||
| You approve before anything bills | , | , | ||
| Audit-ready documentation & full audit trail | , | |||
| Audit & revenue integrity | ||||
| 100% of charts reviewed for missed documentation | , | , | ||
| Ongoing coding audit (completeness & compliance) | , | , | ||
| Documentation-gap feedback to providers (CDI) | , | |||
| Reporting, analytics & fit | ||||
| Reports on acuity mix, top procedures & provider trends | , | |||
| Provider-level feedback to target coding training | , | , | ||
| Works with your existing EHR/PM, no new workflow | ||||
Comparison reflects how these approaches typically work in urgent-care settings; specific vendors and EHRs vary.