1.2 seconds
1.2 seconds: the time an algorithm takes to deny a claim
SOURCES: ProPublica, Cigna PxDx (2023)
For revenue cycle, revenue integrity and denials teams.
Every claim checked against the contract before it goes out. Every payment checked after it comes in.
Lumivera knows the contract, the payer's policy and the regulation as each stood on the date of service. Its agents test every claim before submission, every remittance after payment, and assemble the appeal evidence when the payer is wrong.
Insurers deny in seconds. Hospitals appeal by hand.
1 in 5
1 in 5: in-network claims denied
SOURCES: KFF, ACA Marketplace Claims Analysis (2024)
82%
82%: Medicare Advantage prior authorization denials overturned on appeal.
SOURCES: KFF, Medicare Advantage Prior Authorization (2025)
Up to 65%
Up to 65%: denied claims never resubmitted.
SOURCES: HFMA, Strategies for Proactive Denial Management and Prevention (2018, updated 2025)
Insurers encode each signed contract in their claims engines and push through 100's of policy changes. Hospitals see the effect months later, as lost revenue, with spreadsheets and PDF contracts as the only defense.
Pre-Submission and Post-Remittance Payment Integrity.
Pre-Submission Payment Integrity.
The hospital's own prepay check. Before a claim goes to the clearinghouse, it is tested against the contract rule, the payer policy and the regulation in force on its date of service. Not a scrubber. A check against what the contract says the claim should pay.
Post-Remittance Payment Integrity.
Every remittance line is compared with expected payment computed from the contract in force on the date of service. Underpaid, zero paid, overpaid or correct, each line is classified and rolled up to net revenue and contractual allowance.
We track all ten payer tactics.
Every tactic on this list is a signal Lumivera watches and a rule it checks against. The rule is always the one that applied on the date of service.
| Tactic | Signal | Checked against |
|---|---|---|
| Outlier underpayments | Charges crossed the stop-loss threshold and the base rate was paid | The outlier clause in force on the date of service. |
| Silent repricing | A paid rate that is not in the contract | The fee schedule and amendment lineage. |
| Retro denials | A takeback after payment | The lookback window in the contract. |
| Code drift | The CARC and RARC mix by payer, month over month | Prior months, same payer. |
| Modifier and bundling | Multiple-procedure cuts and lines paid zero | Contract and NCCI rules as of the date. |
| Rate schedule lag | The old year's rates paid after the escalator date | The escalator clause and its effective date. |
| Filing and auth traps | Timely filing and authorization denials | Contract windows by payer. |
| Quality withhold gaps | Withheld dollars not returned | The measure, the period and the return term. |
| Policy updates | The payer policy version applied to the claim | The policy in force on the date of service. |
| Downcoding | DRG and E/M downgrades | The documentation and the payer's own policy version. |
Illinois requires payers to disclose downcoding and allow appeals from January 1, 2028.
SOURCES: Illinois Public Act 104-0568, Transparency in Downcoding Act
Revenue cycle capabilities.
Every check uses the rule as it stood on the date of service.
Payment variance on remittances with auto appeals.
Every short pay found, proved and queued for appeal, with the clause, the policy version and the remit line attached.
Payer downgrade analysis, tracking and appeals.
Every DRG and E/M downgrade tagged with the rule in force on the date of service and the payer's own policy version.
Denial code drift alerts.
A new CARC or RARC pattern from a payer is flagged within days, not quarters.
Retro denial and recoupment tracking.
Every takeback matched to the original remit, the rule in force on the original date and the contract's lookback window.
Appeal evidence in minutes, not hours.
Clause, policy version, remit line and market rate in one packet. Your team or your recovery partner files it.
Appeal outcomes, by payer and reason.
Win rate, dollars recovered against dollars appealed and days to resolution, by payer, denial reason and service line. The system learns which arguments win.
Filing and appeal deadline watch.
Timely filing, appeal and authorization windows by payer and contract, with the dollars at risk of expiring this week.
No Write-Off Threshold: Agents Work Every Dollar.
The small denials and short pays below your team's attention line add up to the thousand cuts. Agents have no threshold. They work every dollar while your team works the big ones.
Why Lumivera's agents know the rule.
A Temporal Knowledge Graph holds every contract, policy and regulation with its effective dates. Agents on frontier models run inside those rules, log every action, and enforce the rules against every claim and every payment. Every decision is traceable to the clause, the version and the claim it came from.
Reads Epic, Oracle Health and your clearinghouse in place.
No migration. No copies. Lumivera adds the rules on top of the records you already keep and hands the work queue back to the tools your team already uses.
Start with what ships today.
Common questions
Revenue cycle questions, answered.
Does Lumivera submit claims or file appeals?
Lumivera checks every claim and every payment and assembles the appeal evidence. Your team or your recovery partner files it. Agents that act on the payer are on the roadmap, and every action they take will be logged and reviewable.
Is Pre-Submission Payment Integrity a claim scrubber?
No. A scrubber checks that a claim is clean. Pre-Submission Payment Integrity checks whether the claim will be paid what the contract says, against the rule in force on its date of service.
How is expected payment computed?
From the contract, the amendment and the payer policy in force on the date of service, not from the contract as loaded today. Every version is kept.
Which denials does Lumivera work?
All of them, including the ones below the write-off threshold. Agents have no minimum.
Does Lumivera replace our RCM system?
No. Lumivera reads Epic, Oracle Health and your clearinghouse in place and sends work back to the queues you already use.
Bring one month of remittances.
We show you every line the insurer paid short, the rule that applied on the date of service, and the appeal evidence for each.
Request a demo