SHIELD
Pre-Submission Denial Defense
SHIELD analyzes every claim before submission to identify and fix issues that would cause denials. By catching errors, missing information, and payer-specific requirements proactively, SHIELD reduces denial rates by 40-60% and eliminates the costly rework cycle.
Key Capabilities
Advanced features designed to maximize your revenue recovery and operational efficiency.
Real-Time Claim Scrubbing
Every claim is analyzed against 500+ edit rules before submission, catching errors that would result in denials.
Payer-Specific Rules Engine
Custom rule sets for each payer ensure claims meet specific requirements, from authorization numbers to timely filing limits.
Documentation Gap Detection
Identifies missing or insufficient documentation that would trigger medical necessity denials before claims are submitted.
Coding Conflict Resolution
Detects code conflicts, bundling issues, and modifier problems that commonly cause claim rejections.
Prior Authorization Verification
Automatically verifies that required authorizations are in place and valid before claim submission.
Predictive Denial Scoring
Machine learning model predicts denial probability for each claim, enabling proactive intervention on high-risk submissions.
How SHIELD Works
A step-by-step look at how our AI agent processes and optimizes your revenue cycle.
Claim Interception
SHIELD intercepts claims in the billing queue before they're transmitted to clearinghouses. This pre-submission checkpoint ensures every claim is analyzed regardless of how it was created.
Multi-Layer Analysis
Each claim passes through multiple analysis layers: demographic validation, coding edits, payer rules, authorization verification, and documentation sufficiency checks.
Risk Scoring
Our ML model assigns a denial risk score based on historical patterns, payer behavior, and claim characteristics. High-risk claims are flagged for additional review.
Auto-Correction
For common, straightforward issues, SHIELD automatically applies corrections. This includes formatting fixes, missing modifier additions, and demographic updates from eligibility responses.
Human Review Queue
Complex issues that require human judgment are routed to a prioritized worklist with detailed explanations and suggested resolutions.
Submission & Tracking
Clean claims are released for submission while SHIELD continues to track outcomes. Denial patterns feed back into the rules engine for continuous improvement.
Technical Specifications
Enterprise-grade capabilities built for scale and compliance.
Edit Engine
- 500+ standard claim edits
- CCI bundling edit integration
- MUE limit enforcement
- Custom facility-specific rules
Payer Intelligence
- 1,200+ payer rule profiles
- Real-time payer update feeds
- LCD/NCD requirement mapping
- Authorization requirement database
Machine Learning
- Denial prediction model (89% accuracy)
- Pattern recognition for emerging issues
- Payer behavior analysis
- Continuous model retraining
Integration
- Clearinghouse API integration
- PM system claim queue hooks
- Real-time eligibility verification
- Authorization system connectivity
Automation
- Auto-correction for 40+ issue types
- Batch processing capability
- Configurable approval workflows
- Exception handling rules
Reporting
- Denial prevention metrics
- Root cause analysis
- Payer performance scorecards
- Staff productivity tracking
Case Study
Real results from urgent care centers using SHIELD.
Urgent Care Network Reduces Denials from 18% to 5%
The Challenge
A 6-location urgent care network in Arizona was struggling with an 18% denial rate, well above the industry average. The denials were costing them over $200,000 annually in lost revenue and rework costs. Analysis revealed the denials were spread across multiple root causes: missing authorizations, coding errors, eligibility issues, and documentation gaps.
The Solution
SHIELD was implemented across all locations with custom payer rules for their top 15 payers. The system began intercepting claims before submission, automatically correcting simple issues and routing complex problems to staff. Within 90 days, the denial rate dropped dramatically.
"Our denial rate was killing us. SHIELD caught problems we didn't even know existed—authorization gaps, coding conflicts, you name it. Going from 18% to 5% denials transformed our cash flow."