Insurance company denied coverage for a patient's 7th therapy visit despite ongoing functional limitation (cannot climb stairs), and the appeals process is complex and often overturned decisions are re-issued.

Workarounds Described

• Requests P2P with referring physician but insurer may use non-specialized physician
• Files appeal with QIO by 12pm deadline, outcome unpredictable
• Files reconsideration appeal up to 2 weeks
• Files appeal directly with health plan if QIO deadline missed
• Provider continues therapy during appeal period hoping to get paid retroactively

Implied Software Gaps

• No centralized system to manage and track multiple insurance appeals with deadlines and compliance
• No AI tool to predict appeal outcome based on similar cases
• No automated generation of appeal letters tailored to insurer requirements

ClaimShield Pro

ClaimShield Pro is an AI-powered denial management and appeals automation platform for healthcare providers. It streamlines the prior authorization and appeals process by automatically generating compliant appeal letters, tracking deadlines, and predicting overturn probabilities, reducing administrative burden and increasing success rates.

Existing Solutions Mentioned