AI Agents & Intelligent Automation
Autonomous agents that assist billing teams by automating manual charge entry, clearinghouse EDI 837 dispatch, and real-time 277 CA status polling to compress days in A/R and lift clean claim rates under human oversight.
What It Automates
Nova Arc's intelligent software agents replace repetitive administrative toil by extracting charges from EHR schedules, scrubbing edits against 1,200+ payer rules, and polling real-time 277 CA claim statuses across payer portals. Engineered to move key RCM metrics—accelerating days in A/R and boosting first-pass clean claim rates—every agent operates with continuous human oversight, routing exceptions and complex edge cases directly to certified billing specialists.
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Autonomous Ingestion & Cleansing: Agents ingest encounter data from Epic, Cerner, MEDITECH, and AthenaHealth, validating patient demographic and insurance COB accuracy.
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Pre-Bill Rule Matching: Automatically compares billing codes against Local and National Coverage Determinations (LCDs/NCDs) and applies correct NCCI modifiers.
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Portal Status Retrieval & Human Oversight: Bots query insurer portals 24/7 to categorize 277 CA rejections, while human billing specialists review exceptions before resubmission.
Pre-Submission Clean-Claim Scoring Engine: 62% → 99.4% Lift
Raw clinical encounters ingested directly from EHR schedules exhibit an average baseline first-pass clean score of just 62% due to complex payer-divergent rules, unbundled surgical codes, and missing electronic attachments. Nova Arc's Payer-Specific Rule Engine interrogates 15,000+ dynamic commercial and CMS policy rules, automatically remediating billing defects in 0.24 seconds to elevate claim acceptance to 99.4% first-pass clean before clearinghouse dispatch.
- -16% PTP Unbundling: CPT 29877 debridement billed with 29881 meniscectomy lacking -XU distinct compartment modifier.
- -12% Missing Attachment: HCPCS C1713 anchor implant absent electronic PWK01/02 manufacturer invoice.
- -6% Missing Facility Indicator: POS 24 billed without commercial payer required modifier -SG.
- -4% COB Segment Imbalance: Secondary crossover adjustment CAS segments failing balancing rules.
- Cross-references operative report; verifies separate patellofemoral compartment & appends modifier -XU.
- Extracts vendor implant invoice from materials management; embeds electronic PWK segment in Loop 2300.
- Appends payer-mandated modifier -SG to line item pursuant to commercial contract terms.
- Reconciles secondary payer coordination-of-benefits CAS segments (CO-45, PR-1, PR-2).
- ANSI X12 837P batch dispatches with 100% SNIP Level 1–7 validation.
- 277CA clearinghouse acceptance returned as A1:19 (Adjudication Ready).
- 100% elimination of avoidable CARC CO-97 / N56 bundling claim rejections.
- Accelerated cash collection into provider bank lockbox within 12–14 days.
Reduction in avoidable technical, registration, and modifier-related clearinghouse rejections.
Faster overall claim velocity from clinical encounter discharge to final electronic cash posting.
Decrease in administrative overhead and repetitive manual data entry labor across billing staff.
Intelligent Authorization
Clinical NLP agents that replace manual payer requirement checking, compile clinical evidence, and track authorization determinations to slash turnaround time and eliminate missing-auth denials.
What It Automates
This capability replaces the labor-intensive manual routine of checking insurer-specific prior-auth rules, gathering clinical progress notes, and logging into fragmented payer portals. By automating auth submissions and status tracking, it drastically shortens authorization turnaround time and eliminates CARC 197 missing-auth denials. Patient access coordinators maintain active oversight, reviewing complex authorizations and managing clinical escalations.
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Clinical Chart Extraction: Clinical NLP scans progress notes to locate proof of conservative therapy, physical therapy duration, and medication history.
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Payer Policy Cross-Reference: Matches proposed procedures (CPT) against live clinical policy bulletins for UnitedHealthcare, Aetna, Cigna, and Medicare.
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Automated Dispatch & Clinical Oversight: Transmits auth packets via payer gateways and tracks status hourly, while clinical intake specialists oversee peer-to-peer and denial reviews.
Autonomous Surgical Prior Authorization: Unstructured EHR → Real-Time EDI 278 Determination
Ambulatory Surgery Centers lose thousands of dollars per operating room hour when surgical cases are delayed or cancelled due to pending pre-certifications. Nova Arc's Clinical NLP reads free-text physician dictations, progress notes, and imaging reports to extract discrete medical necessity evidence (conservative therapy duration, failed NSAIDs, radiographic criteria), maps the payload into ANSI X12 EDI 278 transactions, and secures instant electronic approvals in sub-4 seconds.
BHT*0007*13*REQ20260925*20260925*0830*RQ~ HL*1**20*1~ NM1*PR*2*AETNA*****PI*60054~ HL*2*1*21*1~ NM1*1P*1*VANCE*MARCUS****XX*1982736450~ HL*3*2*22*0~ NM1*IL*1*DOE*JANE****MI*W129384750~ HL*4*3*EV*0~ UM*AR*I*2*24:B~ DTP*472*RD8*20261005-20261005~ HI*BK:M2322*BF:M1711~ SV2*HC:29881*2800.00*UN*1~ PWK*OZ*BM***AC*EHR-PT-NOTE-881~
UM*AR*I*2*24:B~: Prior Auth Review Type, Outpatient ASC SettingHI*BK:M2322~: Primary ICD-10 Diagnosis Mapped Directly from NLPPWK*OZ*BM~: Electronic Attachment Link for PT Records & MRI- Real-time Gateway Transmission via Clearinghouse 278 API
BHT*0007*11*RESP20260925*20260925*0830*AD~ HL*1**20*1~ NM1*PR*2*AETNA*****PI*60054~ HL*2*1*21*1~ NM1*1P*1*VANCE*MARCUS****XX*1982736450~ HL*3*2*22*0~ NM1*IL*1*DOE*JANE****MI*W129384750~ HL*4*3*EV*0~ HCR*A1*AUTH-AET-9948201~ DTP*435*RD8*20261001-20261231~
- OR Block Schedule Preserved: $8,500 ASC contribution margin secured; OR Room 3 kept fully utilized.
- Zero Day-of-Surgery Delays: Pre-cert approved 10 days prior to scheduled surgical booking.
- CARC 197 Immunity: Prior authorization number embedded into Loop 2300 REF*G1 for clean billing.
- Human Escalation Not Needed: 100% autonomous clearance without manual phone hold time.
Need Expert Clinical Staff for Peer-to-Peer Calls, Portal Uploads & Complex Appeals?
While our AI Platform autonomously clears 85%+ of standard surgical pre-certifications via EDI 278, complex non-electronic commercial portals, peer-to-peer physician scheduling, and medical director escalations often require a dedicated clinical touch. Nova Arc’s full-service human RCM pod of certified intake nurses and prior auth coordinators manages the entire end-to-end workflow for your ASC.
First-pass prior-authorization approval rate and complete elimination of CARC 197 missing-auth denials.
Average authorization turnaround time, eliminating care delivery delays and procedure cancellations.
Reduction in administrative staff phone hold times and manual attachment uploading efforts.
Autonomous Coding
Specialized clinical transformer models that assist chart review and suggest ICD-10 and CPT codes to surge coder productivity and shrink DNFB, operating under mandatory human-in-the-loop validation.
What It Automates
Designed to assist professional medical coders, our clinical NLP interprets complex unstructured clinical notes, operative reports, and pathology findings to suggest accurate ICD-10-CM/PCS, CPT, and HCPCS codes. This capability dramatically accelerates coder productivity and reduces Discharged Not Final Billed (DNFB) days. To ensure compliance in this sensitive domain, human oversight is mandatory: certified coders review and confirm all AI-suggested codes prior to final submission.
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Unstructured Clinical Prose Ingestion: Reads physician dictations, operative notes, pathology findings, and emergency triage summaries.
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Autonomous Code & Modifier Assignment: Identifies primary diagnoses, secondary comorbidities (CC/MCC), surgical CPTs, and applies NCCI edit logic.
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Human-in-the-Loop Validation: Rather than unsupervised auto-billing, certified AAPC and AHIMA coders review AI-suggested code sets, verify medical documentation, and approve final claims.
Inpatient Clinical NLP → Autonomous MS-DRG & ICD-10-PCS Grouper Pipeline
Enterprise health systems manage multi-thousand-page inpatient records across dozens of facilities. A single overlooked Major Complication or Comorbidity (MCC) or missing Present on Admission (POA) indicator results in an $8,000 to $25,000 downcoding loss per inpatient discharge. Nova Arc’s Clinical NLP transformer parses multi-document inpatient records, isolates qualifying comorbidities, assigns 7-character ICD-10-PCS surgical codes, and constructs fully compliant, audited 837I billing data in 1.8 seconds.
Multi-Note NLP Ingestion
Consumes H&P, cath lab operative note, ICU flowsheets; runs negation & temporality detection.
SNOMED → ICD-10 Ontology
Normalizes clinical terms; maps to ICD-10-CM diagnoses & 7-character ICD-10-PCS procedural codes.
CMS MS-DRG Grouper
Applies Principal DX selection, checks POA (Y/N), captures CC/MCC tiers, and optimizes compliant CMI weight.
EDI 837I Billable Data
Generates clean Loop 2300 HI/SV2 claim segments with 99.4% confidence for CAC human sign-off.
- Primary Diagnosis maps to MDC 05 (Diseases & Disorders of Circulatory System).
- Cardiogenic Shock (R57.0) satisfies CMS Major Complication/Comorbidity (MCC).
- Elevates encounter from MS-DRG 282 (Base) → MS-DRG 280 (With MCC).
- +$16,650.00 Net Hospital Revenue Optimization under compliance guidelines.
CLM*HOSP892011*26450.00***11:A:1*Y*A*Y*Y~ HI*BK:I2109:Y*BF:R570:Y*BF:I5021:Y~ HI*BR:02HK30Z:D8:20260920*BR:02703ZZ:D8:20260920~ SV2*0110*HC:99223*4500.00*UN*1~ SV2*0250**12000.00*UN*1~ SV2*0481*HC:02HK30Z*9950.00*UN*1~ DTP*434*RD8*20260920-20260924~
- $26,450.00 Full MS-DRG Realized: Zero undercoding leakage; captures accurate clinical acuity.
- DNFB Accelerated by 6.2 Days: Chart coded in 1.8 seconds vs. 48-hour manual backlog.
- 100% OIG Audit Defensibility: Explicit POA indicators verified against emergency presentation.
- CAC Review Ready: Pre-staged for AHIMA certified inpatient coder one-click sign-off.
Looking for Certified Coders (CPC, CCS, CIC) to Audit & Validate Your AI Coding Queue?
Nova Arc pairs our autonomous NLP pipeline with 100% US-based, AHIMA and AAPC-certified inpatient coding pods. Our certified specialists review AI-generated code assignments, manage physician queries, resolve Discharged Not Final Billed (DNFB) backlogs, and audit case-mix index (CMI) integrity under an audited 98.6% accuracy SLA.
Audited coding precision, preventing code mismatch, unbundling, and medical necessity denials.
Average chart coding duration from physician signature to EDI transmission (vs. 24–48h manual).
Reduction in cost-to-code per chart and full elimination of temporary outsourced coding agency premiums.
Engineered for Healthcare Compliance & Zero Data Leakage
We maintain the highest security, privacy, and clinical governance standards in healthcare technology.
HIPAA BAA & Zero Model Training
Your patient health information (PHI) is never used to train public models. All inference operates in isolated, single-tenant HIPAA-compliant containers under formal Business Associate Agreements.
SOC 2 Type II Certified Security
End-to-end AES-256 encryption at rest and TLS 1.3 in transit. Routine third-party penetration testing, role-based access control (RBAC), and continuous SIEM audit logging.
Human-in-the-Loop Defensibility
Deterministic confidence thresholds ensure low-certainty or unusual charts are intercepted and audited by AAPC/AHIMA certified specialists before clearinghouse submission.
Experience the Future of Autonomous Healthcare RCM
Schedule a personalized 20-minute live demonstration of the Nova Arc AI Platform and receive an algorithmic assessment of your health system's recoverable denial opportunities.