AgentHack submission type
Enterprise Agents
Name
Sagar Kurhekar
Team name
ClaimShield
How many agents do you use
One agent
Industry category in which use case would best fit in (Select up to 2 industries)
Healthcare Pharma
Complexity level
Advanced
Summary (abstract)
ClaimShield is GenAI powered agent that helps medical billing teams predict potential claim denials by validating claims against payer policies for CPT codes as well as historical denials.
- Our agent uses structured features (e.g. patient DOB, Gender etc.) as well as unstructured payer policies to flag claims for potential denails
- Our agent is grounded in payer specific CPT code guidelines as well as historical claim denials
- It leverages UiPath AgentBuilder to create a structured prompt togther with context grounding mentioned in #2 .
- Agent predicts below fields for each claim -
a. Verdict - Likely to be denied/ Likely to be accepted/Unable to determine
b. Reasoning - Justification against verdict
c. Suggestions -Detailed Suggestions to improve claim further - UiPath robot reads input claim data , triggers agent , formats output and sends a consolidated report to medical billing team
Detailed problem statement
Healthcare providers and revenue cycle teams face significant financial losses and operational inefficiencies due to medical claim denials. A substantial proportion of these denials are preventable, often resulting from issues like incorrect coding, or non-compliance with payer-specific rules/policies. Manually identifying and addressing such risks before claims are submitted is time-consuming, error-prone, and lacks scalability.
Many organizations currently lacks an automated, proactive system to analyze claims for denial risks prior to submission. As a result, preventable denials increase administrative costs, delay reimbursements, and strain resources required for appeals and rework.
Although existing solutions use statistical ML models to predict potential denials, they lack in utilising unstructured payer policies
Detailed solution
ClaimShield agent uses payer specific guidelines ,exclusion policies & rules against CPT codes as knowledgebase (context grounding) for validating incoming claims and predict potential denials.
It also uses historical claim denial data as additional input for making the prediction
It compares unstructured patient chart , treatment details as well as structured information like patient DOB, treatment date etc. against payer rules , identifies patterns from historical denials and predicts if claim will be denied / accepted
It sends a report to billing team for review
Demo Video
Expected impact of this automation
ClaimShield Agent proactively identifies and prevents potential claim denials by analyzing unsubmitted claims to identify potential mismatches with the CPT codes applied versus payer specific guidelines . This reduces revenue loss and accelerates cash flow for healthcare providers while improving claim accuracy and compliance. Finally this reduces rework on appeals for denied claims.
UiPath products used (select up to 4 items)
UiPath Agent Builder
Automation Applications
Excel
Integration with external technologies
EMR like EPIC, OpenEMR - Future Enhanement Planned
Agentic solution architecture (file size up to 4 MB)
Sample inputs and outputs for solution execution
Input :ayer:
UHC
cpt_code:
94067
treatment_description:
Patient presented for evaluation of a medical condition requiring diagnostic or therapeutic services. Physical examination was performed, and findings were consistent with impacted cerumen. As part of the evaluation, the provider performed spirometry to assist in diagnosis or management. Patient was advised on follow-up care and informed of potential warning signs requiring immediate medical attention.
tratement_date:
2025-05-15
patient_DOB:
1988-08-06
Output :
esponse:
- Verdict: Likely to be accepted
- Reason: CPT code 94067 for spirometry is excluded by UHC only for patients under age 5. The patient, born on August 6, 1988, is 36 years old at the time of treatment, which is well outside the exclusion age criteria. The treatment description aligns with the use of spirometry for diagnostic purposes.Historical denials doesn’t suggest any potential denial trend for similar claims
- Suggestions: Ensure thorough documentation of the spirometry procedure and the clinical indication supporting its medical necessity. No modifiers or alternative CPT codes are required based on current UHC exclusion policies.
Other resources
PPT Link : ClaimShield AgentHack.pptx - Google Slides