The Real-World Problem
A primary care practice submits a routine office visit for an established patient with active Blue Cross coverage. All CPT codes are valid, prior auth is not required, and the fee schedule match is exact. This is the best-case path that revenue cycle teams want every claim to follow.
Agents Carrying the Load
Claim IntakeCoverage VerificationAdjudication
Claim Intake extracts the structured 837P fields using Document Intelligence. Coverage Verification confirms active membership. Adjudication applies the fee schedule and produces a clean ERA.
Financial StakesIn a 500-bed hospital system, roughly 65% of claims should follow this path. Any deviation raises cost per claim from $0.10 to $2-3 in manual rework.