PreClaim
Pre-Encounter Evidence Layer

Every payer has rules.
Your chart has evidence.
We connect them — before the visit.

PreClaim continuously ingests payer coverage rules, matches them against your patient's existing documentation, and surfaces only what's missing — inside your EHR, before anyone sits down.

See How It Works View the claim journey
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Your EHR
Patient scheduled for facet injection
CPT 64493 · Aetna PPO · 3 days from now
PreClaim activates silently
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PreClaim — Evidence Assembly
Records pulled. Payer rules loaded.
LCD L35936 matched. 4 of 6 criteria satisfied from existing chart.
2 gaps: PT notes + conservative care log
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Front Desk Sees
Task appears on coordinator's schedule
No new tab. No new login. Right inside the existing appointment view.
Request PT notes from referring provider
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Provider Sees
Guidance note attached to encounter
Document conservative care failure (6+ weeks PT) and current VAS score for LCD compliance.
Specific to this payer + this CPT
LCD L35936 updated Mar 2026 — new VAS threshold
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Result
Claim goes out clean. First pass.
All LCD criteria met. RFA complete. No denial to chase.
Score: 94 — Ready
What Powers It

Three intelligence layers.
Running before every visit.

PreClaim doesn't guess. It matches your patient's chart against the payer's actual adjudication criteria — informed by real denial outcomes.

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Payer Coverage Rules
LCD + commercial criteria per CPT, per payer. Continuously updated. Not a static checklist — a living policy graph that tracks rule changes as payers publish them.
Auto-ingested from CMS + 14 commercial payers
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Pre-Encounter Evidence
What documentation already exists — pulled from HIE networks, claims history, and your EHR. Assembled before the visit, not after the denial.
320M+ patients via CommonWell + Carequality
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Denial Pattern Intelligence
What documentation gaps actually caused past denials — by payer, CPT code, and market. Real 835 remittance data feeding back into every score.
Feedback loop from adjudication outcomes
Where We Sit

One window in the claim lifecycle.
Currently empty. Ours.

Most tools react after a denial. PreClaim fills the window where prevention is still possible — and cheap.

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PreClaim Zone
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Evidence Assembled
Automatic. Before visit.
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PreClaim does not replace your EHR, billing company, or clearinghouse. It fills the window between scheduling and visit — a window that currently has no tooling in most practices.
How It Works

Runs automatically. Surfaces only
what needs a human.

From the moment a patient is scheduled, PreClaim is working. Your staff interact with it only when something genuinely needs them.

Step 01 — Automatic
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Patient Scheduled.
PreClaim Activates.

Appointment confirmed in your EHR. PreClaim pulls medical records via TEFCA, loads payer rules per CPT code, checks prior auth history, scans denial patterns. No staff action.

→
Step 02 — Intelligent
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Evidence Matched.
Gaps Flagged Precisely.

LCD and commercial payer criteria matched against what's in the chart. 85–95% assembled passively. Remaining gaps are specific — not “review documentation.”

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Step 03 — Ambient
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Guidance Delivered.
Inside Your EHR.

Front desk sees exactly which appointments need action. Providers see precisely what to document. No new system. No new tab. Notes and tasks appear in your existing workflow.

Ambient by Design
Your coordinator doesn't open a new tab.
PreClaim does its job before they sit down.

Staff won't toggle between systems. Physicians won't change how they document. So PreClaim doesn't ask them to.

When a patient is scheduled, PreClaim activates silently — pulls records, checks payer policy, scores readiness, and flags only what genuinely needs a human. Everything else is already handled.

Who sees what
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Front Desk / Coordinator
Sees which scheduled appointments have gaps. Knows exactly what to request — PT notes, imaging, prior auth letters.
Task list inside your EHR schedule
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Provider / Physician
Walks into the room with a complete pre-populated RFA. Knows exactly what to document for this payer, this CPT, this patient.
Guidance note attached to encounter
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Billing Team
Claims go out clean on first pass. Denial rate drops. No more chasing records 30 days later.
Clean claim on day of service
What Changes

Same claim. Different outcome.

The evidence isn't assembled before the claim leaves — and by then, fixing it costs more than it's worth.

Without PreClaim — Today
Scheduled. No evidence check. Chart is empty.
Visit happens. Missing PT notes. Imaging outdated. Conservative care undocumented.
Claim filed with whatever's in the chart. Doesn't satisfy the LCD.
DENIED. CO-50. $380 on hold for 45–90 days.
65% never appeal. Revenue written off. Repeats next month.
With PreClaim — Preventive Standard
Scheduled. PreClaim activates. Assembly begins. No staff action.
Evidence assembled passively. History, imaging, auth status, LCD criteria — via TEFCA networks.
Gaps filled before visit. Coordinator sees exactly what's needed. Provider gets specific guidance.
Physician walks in ready. Complete RFA on file. Docs match the auth exactly.
Paid — first pass. No appeal. No rework. No abandoned revenue.
Solutions

PreClaim works in your world.
Not the other way around.

Clinic, billing company, or software platform — PreClaim fits into what you already do.

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For Clinics & Practices
You run a practice.
Not a software stack.

Your coordinator chases auth records all week. Your biller watches denials land 30 days later. The problem is timing.

PreClaim connects to your EHR. Your staff sees exactly which appointments need action — and what action. No new system to learn.

For Clinics & Practices →
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For Billing Companies & RCM Firms
Your clients pay you to recover denials.
Imagine preventing them instead.

Every RCM firm is reactive — you fight denials after they happen. Your clients are asking why they keep happening.

Embed PreClaim and add pre-submission intelligence to every claim you manage.

For Billing Companies →
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For Software Platforms & EHR Vendors
Your customers want better prior auth tools.
Building it takes years.

Your customers keep asking for payer intelligence. Building a policy engine takes years and millions.

PreClaim's PolicyGraph API gives you LCD matching, evidence scoring, and denial prediction — embed in weeks.

For Software Platforms →
Stop fixing denials after the fact

See PreClaim
in action.

20 minutes. We'll show you exactly where your practice is losing revenue — and how fast you can stop.

HIPAA-Compliant · No PHI Required · Cancel Anytime