- An agent in H2O AI Super Agent reads the denial, gathers the supporting chart documentation and payer policy, and drafts the appeal letter with the governing clause cited.
- A model in H2O Driverless AI can rank the denial queue by the chance an appeal is paid and the amount at stake, so your team works the most valuable claims first.
- Nothing goes to a payer until your specialist approves it, and the first runs happen in shadow mode against past denials before touching a live claim.
- H2O supports HIPAA and HITECH requirements, and protected health information never has to leave your boundary.
Work the highest-value denials first
Your denial specialists read a rejection code, open the chart, hunt for the documentation that supports the claim, find the payer's policy clause and write the letter by hand. Then they track the response and do it again for the next claim.
Most teams work the queue in the order it arrived, not by what it is worth. The care was delivered and documented. What costs you is the labor of proving it, one claim at a time.
How AI denials and appeals work
The workflow combines three kinds of AI. Predictive AI ranks the queue, generative AI reads documents and drafts text, and AI agents carry the work across the systems you connect.
Step 1: read the denial
Document AI, the extractors in Enterprise h2oGPTe, reads denial letters and payer correspondence with intelligent character recognition and returns the claim, payer, denial reason and deadline as structured fields.
Step 2: rank the queue
A model built in H2O Driverless AI scores each denial on the chance an appeal is paid, with explainable AI reason codes. Your team sees which claims are worth working first.
Step 3: gather the evidence
The agent pulls the relevant notes, orders and results from the systems you connect, and retrieves the payer policy clause from a collection you maintain. Each retrieved passage carries a reference to its source.
Step 4: draft the appeal
The agent writes the appeal letter in your template, with the governing clause and the supporting documentation cited.
Step 5: review and sign
Your denial specialist edits, approves and submits the appeal through your existing process. The agent stops at an approval gate and does not submit anything on its own.
Denial prediction before the claim goes out
The same ranking model can score claims before submission. A claim that looks like past denials goes back to your billing team for a check first, which is cheaper than an appeal later.
Governance for revenue integrity
Denials work sits in revenue integrity, where a wrong action costs money and creates a compliance question at the same time. The agent drafts and your specialist decides, with governance over what each agent may read and touch. The first run is shadow mode on last quarter's denials, with a baseline measured in week one.
H2O supports HIPAA and HITECH requirements, and protected health information never has to leave your boundary. H2O makes no clinical efficacy claim: the agent works on documentation and payer rules, and your team keeps every decision.