The first AI-native end-to-end RCM platform
ClaimVise replaces your medical coding floor with a coordinated team of seven autonomous AI agents. They read clinical notes, code claims against sixteen specialty rule sets, scrub against 476 CCI edits and twenty-one payer policies, predict denials before submission, and write evidence-based appeals when claims come back. One platform, one price, full audit trail.
The agent team
Every legacy RCM tool wraps software around a coding team. ClaimVise replaces the team. These seven agents read every note, code every claim, catch every preventable denial, and log every decision. A human supervisor reviews the exceptions. The agents handle the rest.
Reads clinical documentation in any format.
Physician dictation, typed clinical notes, PDF superbills, handwritten notes, MAR exports from OncoEMR. Extracts assessment diagnoses, documented procedures, time spent, and infusion data into structured output ready for the Coding Agent.
Assigns ICD-10 and CPT codes across sixteen specialties.
Two-pass architecture: a fast model reads the structured extraction, a stronger model codes against specialty rule sets covering oncology, cardiology, orthopedics, psychiatry, internal medicine, and twelve others. Every output carries a confidence score.
Validates every claim against deterministic payer rules before AI gets a vote.
476 CCI edits for procedure bundling, 47 modifier rules for JZ, JW, KP, KQ, Q0, Q1, XU per CMS, and 21 payer-specific policies covering Medicare, Medicaid, Aetna, Anthem, BlueCross, Cigna, UnitedHealth, and Humana. If a rule says no, the claim does not move.
Scores claim risk before submission.
Hybrid architecture. The rules engine scores known violations: critical 40 points, high 20, medium 10. A second pass adds AI risk adjustment from learned patterns. Final score routes the claim to low, medium, high, or critical risk lanes.
Writes payer-specific appeal letters using the original clinical note as evidence.
Pulls the assessment diagnosis, documented procedure, medical necessity language, and payer's adjudication patterns. Generates a letter ready for supervisor review in seconds, complete with clinical citations and regulatory references.
Verifies every drug billing unit against CMS HCPCS and FDA labeling.
89-drug dictionary covering oncology infusions, IVIG, biologics, and biosimilars (Q5107, Q5112, Q5113, Q5114, Q5117). Multi-drug reconciliation from MAR data. When a billing unit cannot be sourced from authoritative data, the agent refuses to bill and flags the line for human review.
Logs every PHI access and every agent decision with cryptographic integrity.
SHA-256 integrity hash on every event, verified on every read. Meets HIPAA §164.312(b). Tamper-evident by design. Every change to a claim, override by a supervisor, approval, and appeal sent is recorded with actor, timestamp, and outcome.
The problem
Offshore BPOs cost eight to fifteen dollars per claim in labor and take two days to turn one around. Legacy RCM software costs three hundred to eight hundred dollars per month plus four to eight percent of collections, and still requires a coding team behind it. Both approaches assume humans do the work and software helps them. ClaimVise inverts that. The agents do the work. A human supervisor handles exceptions.
How it works
Six steps. Each one is an agent acting on a specific decision. Zero handoffs to a human until something the agents flag for review.
The Scribe Agent accepts dictation, typed notes, PDF superbills, handwritten charts, OncoEMR MAR exports, or batch CSV.
The Coding Agent runs a two-pass extraction with specialty routing. Below 75% confidence, the case escalates to a stronger model automatically.
The Scrubbing Agent validates against 476 CCI edits, 47 modifier rules per CMS, and 21 payer-specific policies. Deterministic.
The Denial Prediction Agent scores submission risk 0 to 100. Critical-risk claims are blocked until a supervisor reviews.
A complete CMS-1500 is produced, ready to submit through your existing clearinghouse workflow.
If a claim is denied, the Appeal Agent drafts a payer-specific letter using the original clinical evidence.
Platform depth
The reason ClaimVise replaces a coding floor instead of just speeding one up is everything underneath the agents: a four-layer configurable rules engine, an authoritative drug dictionary with provenance, deterministic post-processing validators, and a multi-tenant architecture that lets the same platform serve a solo practice and a fifty-practice BPO with completely different billing methodologies.
Four-layer configuration: System → BPO → Practice → Payer. Different BPOs bill differently. Different practices within a BPO bill differently. Different payers reject different things. ClaimVise resolves all four into a single billing decision per claim.
Example: Anthem rejects KP and KQ modifiers, so the payer layer sets vial decomposition mode to "combined" for Anthem claims. The same practice's Medicare claims still bill with KP and KQ.
89 drugs sourced from CMS HCPCS Level II and FDA labeling. Every billing unit verified against authoritative data. Source Document Verified flag marks confidence. Where data cannot be confirmed, billing units are set to none rather than guessed.
Coverage: oncology infusions, IVIG, biosimilars (Q5107, Q5112, Q5113, Q5114, Q5117), monoclonal antibodies, biologics, and routine office medications.
After the agents run, three deterministic validators check the output: multi-line unit sums, modifier consistency (JZ/JW, KP/KQ, SDV), and name-authoritative drug codes. The core apply_modifiers function is byte-frozen behind SHA-256 hash regression tests.
This is how we promise zero hallucination on modifier assignment. The math is not allowed to drift.
Coordinates which agents run, in what order, with what escalation policy. Async batch capable. Confidence-routed. Per-claim configuration. Decides whether a claim needs the full agent stack or just a subset.
Built to scale: 200 notes processed concurrently, rate-limited at 50 requests per minute per practice with exponential backoff retry.
Engineering rigor
Healthcare billing AI is not the place for "ship fast, fix later." Every change to our coding pipeline runs against a 555-test regression suite before it merges. Every modifier decision is locked behind a cryptographic hash. Every PHI access is audited with integrity verification.
Every code change ships against a 555-test regression suite covering the coding agent, validators, scrubbing engine, modifier rules, drug dictionary, billing configuration, and seven real clinical notes including dense oncology infusion cases. The full suite must pass 555 of 555 before a change merges. Zero exceptions.
The function that applies modifiers (JZ, JW, KP, KQ, Q0, Q1, XU) per CMS specification is hash-anchored. Any change to the bytes of that function fails three independent regression tests. The math that worked yesterday still works today, guaranteed.
AWS Business Associate Addendum executed May 22, 2026. All Claude inference routes through AWS Bedrock under that BAA. SHA-256 integrity-hashed audit trail meets §164.312(b). PHI never leaves a HIPAA-eligible AWS region. JWT auth, rate-limited endpoints, magic-byte file validation, and full multi-tenant isolation.
When the Drug Reconciliation Agent cannot verify a billing unit from authoritative CMS HCPCS or FDA data, it does not bill. It flags for human review. When the Coding Agent's confidence drops below 75%, it escalates rather than guessing. When the Scrubbing Agent finds a CCI violation, the claim does not move. We say no when we should say no.
How we compare
We are not a faster offshore BPO and we are not a sharper Waystar. We are a different category. Here is what changes when AI agents do the work and a supervisor handles exceptions.
| Dimension | Offshore BPO | Legacy RCM Software | ClaimVise |
|---|---|---|---|
| Who does the work? | Human coders + supervisors | Human coders, software organizes them | Seven AI agents, one supervisor reviews exceptions |
| Cost model | $8 to $15 per claim (labor) | $300 to $800/mo + 4 to 8% of collections | $1 per claim, flat |
| Setup time | 4 to 8 weeks (hiring & training) | 60 to 90 days (implementation) | Same day |
| Coding accuracy | 85 to 88% | Depends on coders | 95%+ |
| Denial rate | 11 to 16% | 9 to 13% | 5 to 8% |
| Staff per 500 claims/day | 8 to 12 FTEs | 4 to 6 FTEs + software | 1 supervisor |
| Coding turnaround | 24 to 48 hours | 24 to 48 hours | Under 10 seconds |
| Payer rules | Tribal knowledge | Static rule library | 21 seeded + configurable per practice and per payer |
| Audit trail | Manual logs | Often partial | SHA-256, §164.312(b), AWS BAA |
| Availability | Business hours (timezone gap) | 24/7 software, business-hour support | 24/7/365 |
| Engineering rigor | N/A | Quarterly releases | 555-test regression gate, every change |
Pricing
Choose per-claim or fixed monthly. All tiers include every agent, every module, full platform access. No per-seat fees, no module upcharges, no surprises. Local currency pricing available in INR and USD.
Start with 1 practice
Up to 5 practices
Up to 15 practices
Vision and roadmap
What you have read above is what runs in production today: clinical note to claim submission, fully automated, live at v5.0. Over the next four to six weeks, we ship the rest of the revenue cycle. These features extend the agent architecture into operations.
Real-time benefits verification through Availity API. Pre-visit verification, CPT against plan benefits, copay and deductible calculation.
Detects prior auth requirements before scheduling. Drafts clinical necessity letters. Submits to payer portals. Tracks approval status.
Parses 835 electronic remittance advice files. Auto-posts payments against claims. Flags underpayments against contracted rates.
Monitors claims by aging bucket. Generates follow-up actions based on payer-specific aging patterns. Routes to the appropriate workflow.
Direct electronic claim submission to Change Healthcare, Availity, and Trizetto. Full submission tracking and acknowledgment processing.
Bi-directional integration with AdvancedMD, Kareo, athenahealth, and DrChrono. Claims flow in and out automatically.
Identifies underpaid claims, builds payer negotiation strategy, generates supporting data packages for recovery.
Roadmap commitments are subject to change. Active customers receive weekly progress updates on Q3 and Q4 deliverables.
FAQ
There is a real difference between an RCM product that adds AI features and an RCM product where AI agents do the work. Legacy RCM software is a workflow tool. It routes tasks, tracks status, and recently added an AI assistant in the UI. Coders are still human. Denial reviewers are still human. Appeal writers are still human. ClaimVise is built the other way. Seven autonomous agents read the note, code the claim, scrub it against payer rules, predict denials, write appeals, and reconcile drug billing. The platform routes work between them. A human supervisor handles exceptions. The agents are the workforce, the supervisor is the manager.
Yes. Every claim is processed under our AWS Business Associate Addendum, executed May 22, 2026. All Claude inference routes through AWS Bedrock under that BAA, so PHI never leaves a HIPAA-eligible AWS region. Every event is logged with a SHA-256 integrity hash verified on every read. Our audit trail meets §164.312(b) requirements. We sign a BAA with every paying customer.
Different model, different math. A BPO charges eight to fifteen dollars per claim in labor cost and takes 24 to 48 hours to turn one around. ClaimVise costs one dollar per claim, processes in under 10 seconds, hits 95% coding accuracy versus the 85 to 88% human industry average, and cuts denial rates roughly in half. Our BPO Partners page walks through the per-practice economics in detail.
ClaimVise is an AI-native platform, not workflow software wrapped around a manual coding team. Legacy RCM tools manage the workflow but you still need coders, scrubbers, and denial specialists. We replace those functions, not just organize them. Our platform also ships capabilities those tools do not have: oncology MAR reconciliation, real-time denial prediction with hybrid rules and AI scoring, multi-tenant configurable billing methodology per BPO and per practice, and a drug dictionary that refuses to bill when authoritative data is missing.
95% and higher on production claims. Our Coding Agent uses a two-pass approach. A fast model extracts structured data from the note: assessment diagnoses, documented procedures, time spent, infusion details. A specialty-aware second pass codes against sixteen specialty rule sets. Below a 75% confidence threshold, claims escalate to a stronger model automatically. Our regression suite of seven real clinical notes, including dense oncology infusion cases with MAR data, passes 7 out of 7.
All seven agents: Scribe, Coding, Scrubbing, Denial Prediction, Appeal, Drug Reconciliation, and Audit. All platform capabilities: multi-tenant billing configuration, file import portal, batch processing up to 200 notes, revenue dashboard, notifications, fee schedule lookup, and the full HIPAA audit trail. Platform infrastructure, AWS BAA coverage, and email support. There is no add-on pricing for any of it.
Same day for a single practice. Create an account, configure your practice profile (NPI, tax ID, payer mix), upload your first note. For BPO white-label deployments with dedicated VPS instances and custom branding, five business days. There are no 60-day implementation projects.
Today, we accept clinical notes and superbills from any EHR via PDF, image, or CSV export, and we support PMS column mapping for batch claim imports. Bi-directional integrations with AdvancedMD, Kareo, athenahealth, and DrChrono are on the Q4 2026 roadmap. If you use a specific system, tell us during the demo and we will prioritize accordingly.
You will not need a coding floor anymore. That is what the agents replace. You will still want a supervisor in the seat: reviewing exceptions, managing agent configuration, handling the small percentage of cases that need human judgment. Most customers redeploy their best billers into that role; the work becomes higher leverage and the headcount drops. Practices typically go from four to six coders to one supervisor. BPOs go from ten to fifteen to two or three.
See it live
Book a 30-minute call. Bring a clinical note. Watch the platform code, scrub, predict, and generate a CMS-1500 in front of you.
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