| Claim ID | Patient | CPT / ICD-10 | Payer | Charge | Denial Risk | Agent Status |
|---|
CPT 27447 (Total Knee Arthroplasty) requires prior auth for UnitedHealthcare. None found in record.
Bilateral modifier -50 applied but documentation supports unilateral procedure. G-ARVIS Accuracy score: 0.41 (FAIL).
ICD-10 M17.11 — clinical notes reference conservative treatment but no structured documentation of failed alternatives. G-ARVIS Reliability: 0.52 (WARN).
| Payer | Claims | Denial Rate | Top Reason | Avg Resolution | ARIA Agent Action |
|---|---|---|---|---|---|
| UnitedHealthcare | 2,847 | 14.2% | Prior Auth (38%) | 32 days | Auth Checker Agent: pre-submit enabled |
| Aetna | 1,923 | 9.8% | Med Necessity (42%) | 28 days | Coding Validator: doc template deployed |
| Blue Cross Blue Shield | 3,156 | 6.1% | Coding Errors (31%) | 21 days | Coding Validator: auto-validation active |
| Cigna | 1,482 | 11.3% | Eligibility (29%) | 35 days | Auth Checker: real-time eligibility added |
| Medicare | 4,291 | 4.7% | LCD/NCD (45%) | 18 days | Denial Predictor: coverage pre-check |
187 claims paid below contracted rate for CPT 99213-99215. Variance: -$42.30 avg per claim.
Documentation supports 99214 but 99213 was billed on 94 encounters. Uplift: $3,760.
Lab and imaging charges missing from 63 surgical encounters. Total: $28,420.
Based on the simulated analysis of a mid-size health system processing 13,699 claims per quarter with 11 autonomous agents.
0.967
98.2%
$0.034
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