Medical Coding & Claims Auditor
Finds the reason the claim will be denied, before you submit it
- 8hard rules
- Things it must never do, enforced in every run
- 5handover rules
- Conditions where it stops and gives the work to a person
- 7output fields
- A structured result, not a paragraph you have to re-read
- ≤6steps per run
- Bounded work: at most 5 tool calls, enforced by the runtime
Read-only by design. This agent has no path to sending, spending, publishing or committing anything. Where that limit is the product, removing it would remove the reason to trust the output.
Overview
Most claim denials are administrative, not clinical: a code the note does not support, a missing modifier, an authorisation nobody obtained, a place-of-service mismatch. Each one is rework, and rework at volume is the largest avoidable cost in a billing operation.
This agent checks a coded claim before it goes out. It compares each code against what the documentation actually records, checks the claim against the payer rules in your knowledge base, and reports what would cause a denial — with the rule and the part of the note that does or does not support it.
It does not assign codes, does not diagnose, and does not assess whether treatment was appropriate. Those are a clinician's and a certified coder's work. It reads what was written and what the payer requires, and reports where they do not meet. Everything it produces goes to a person to act on.
Benefits
Fewer denials
Caught before submission, when fixing costs minutes instead of weeks.
Faster review
Coders see only claims with a flagged reason, each already evidenced.
A defensible record
Every flag traces to a rule and a line of the note.
What it does
Checks code against documentation
Whether the note actually records what the code claims, quoting the part that does or does not.
Applies your payer's rules
Read from your knowledge base, so it is that payer's policy rather than a generic ruleset.
Catches the administrative denials
Missing modifiers, authorisations, place-of-service mismatches, and required attachments.
Separates unsupported from undocumented
A code the note contradicts and a code the note is silent on are different problems with different fixes.
Assigns nothing
It reports; a certified coder decides. Coding is a credentialed act and stays one.
Never clinical
No diagnosis, no assessment of whether care was appropriate.
What this changes
What this changes about your week
- It takes over
- Checking coded claims against documentation and the payer's own rules before submission.
- Done today by
- Certified coders, at the limit of their capacity.
- How often
- Every claim batch.
- Typical manual effort
- A pre-submission scrub of a batch is hours.
Why Healthcare in particular. Most denials are administrative, not clinical. Rework at volume is the largest avoidable cost in a billing operation.
Runs unattended
Started by you or by an event, and it finishes on its own. Nothing waits for someone to be at a desk.
The same standard every time
The two-hundredth item is held to the bar the first one was. Consistency is the part people cannot sustain.
It cannot act on its own
Medical Coding & Claims Auditor has no path to sending, spending or committing. That limit is why its output is safe to act on.
How it runs
This agent runs server-side through the PROMIVO runtime. Each run is logged step by step and every tool call is permission-checked before it executes.
- 1InputValidated against the agent input schema
- 2Modelclaude-opus-5 with automatic fallback
- 3Toolssearch_knowledge, extract_structured_data
- 4PermissionsRuns READ actions automatically; anything higher waits for approval
- 5OutputStructured result matching the output schema
- 6LoggingTokens, duration and every step recorded
Demo
Demo dataIllustrative sample output, abridged.
Input
{
"codes": [],
"payer": "Regional Health",
"documentation": "…",
"claimReference": "CLM-9931"
}Output
{
"escalate": false,
"findings": [
{
"code": "99214",
"rule": "Level 4 established patient visits require documented medical decision-making of moderate complexity, or total time.",
"issue": "not-documented",
"sourceDocument": "Regional Health Provider Manual 2026 — section 7.4",
"denialLikelihood": "likely",
"documentationSupport": "The note records a brief follow-up with no examination findings and no time recorded. Nothing in it addresses the level billed."
}
],
"disclaimer": "A documentation and payer-rule check. Not coding advice, not a clinical opinion, and not a finding that this claim is correct or payable. A certified coder must review.",
"payerRulesFound": true,
"observationsForCoder": [
"The documentation as written appears to describe a lower level of service. This is an observation, not a code assignment."
]
}Requirements
Integrations
No integrations required.
Before you start
- The coded claim and the supporting documentation
- A knowledge base holding the payer's policies and coding requirements
- Requires the All-Access plan or higher
Use cases
Pre-submission scrub
Check the batch before it goes to the payer.
Denial analysis
Find the pattern behind a run of denials.
Documentation feedback
Show clinicians which notes routinely fail to support coding.
Pricing
All-Access
Billed monthly through your PROMIVO subscription. Cancel at any time.
Runs consume your plan allowance for agent executions and tokens. See plan limits
FAQ
Does it assign codes?
No. Coding is a credentialed act with legal weight. It checks codes already assigned against documentation and payer rules, and reports discrepancies for a coder to resolve.
Is this clinical?
No. It never diagnoses, never assesses whether care was appropriate, and never comments on a clinician's decisions. It reads what was documented and what the payer requires.
What about patient data?
Supply de-identified records wherever possible; the audit works from documentation and codes, not from identity. Your own handling of protected health information remains your responsibility, and this agent does not transmit records anywhere.
What if we have no payer rules loaded?
It checks documentation support only and says the payer check could not be performed. It will not substitute a generic ruleset for the payer's own.
Reviews
Reviews open once customers have run this agent.
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