Evals for RapidClaims

ICD / CPT / E&M code selection from chart text

Correct primary and secondary code assignment, specificity, and sequencing from progress notes, op notes, and discharge summaries.

Evidence and guideline citation for every code

Each assigned code maps back to the specific chart passage plus the governing ICD/CPT/E&M, LCD/NCD, or NCCI rule; no unsupported codes.

Confidence thresholds and escalation to human coders

Ambiguous or complex charts route to a certified coder with full context instead of being auto-finalized.

Specialty and setting variation

Behavior across the specialties and care settings the platform claims to cover, including E&M leveling differences by setting.

Gap detection prior to code assignment

Identifying missing specificity, unsupported diagnoses, and conflicting documentation before a chart moves to billing.

Compliant, non-leading query drafting

Queries present clinical evidence and options without steering the physician toward a higher-reimbursing answer.

Missed HCC and SDOH opportunity surfacing

Flagging conditions and social determinants supported by the record but absent from the coded set.

Query lifecycle and response handling

Tracking open queries, incorporating physician responses, and reconciling the final coded chart.

HCC suspecting from labs, meds, and narrative notes

Surfacing conditions implied by supporting clinical data but never coded, with the evidence chain attached.

Chronic condition annual recapture

Identifying conditions requiring recapture in the current year and distinguishing them from newly suspected diagnoses.

V24 to V28 model handling

Correct category mapping and RAF behavior across model versions, including codes that change or drop status.

Document ingestion, classification, and date correction

Auto-classifying uploaded documents and resolving missing or inaccurate dates into a coherent patient timeline.

NCCI edits, modifiers, and bundling logic

Detecting unbundling, missing or invalid modifiers, and mutually exclusive procedure pairs before submission.

Payer-specific rule application

Applying the correct payer's documentation and policy requirements, including learning from that payer's prior denials.

Split claims, COB, and timely filing windows

Correct handling of secondary payers, claim splitting, and payer-specific submission deadlines.

Same-day drop and clean-claim outcomes

Claims released without manual rework, with edits either resolved or explicitly routed for human decision.

Denial categorization and root cause tagging

Classifying each denial by payer, code, and cause — eligibility, coding, authorization, medical necessity, timely filing, bundling.

Risk scoring and worklist prioritization

Ranking denials by recovery probability and dollar value; routing complex cases to staff with context attached.

Payer-specific appeal letter drafting

Appeals built around the specific payer's rules and documentation requirements, citing the chart evidence that rebuts the stated reason.

Supporting documentation assembly

Attaching the correct records for the denial reason without over-disclosing unrelated patient information.

Historical-data benchmark reporting

Side-by-side comparison against the customer's own baseline, with accuracy delta and denial-rate projections stated honestly.

Few-shot adaptation to customer conventions

Learning site-specific workflows and coding conventions from a limited chart sample without overfitting to noise.

Audit trail and compliance defensibility

Every autonomous decision reconstructable after the fact for an HIM auditor or payer audit.

Role-based views and human override

CDI, coding, denials, and finance views reflect the same underlying state; human corrections are respected and retained.