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PRE-SUBMISSION CLAIMS INTELLIGENCE

Catch Denial Triggers
Before They Cost You

AI-powered claims validation that sits upstream of your adjudication engine. Increase auto-adjudication rates, reduce manual review queues, and cut avoidable denial costs.

AGENT PROCESSING
01EDI 837P parsed — 3 procedure lines identified
02Cross-referencing UHC commercial rule set v2026.03
03Prior auth required for CPT 72148 — no auth found
04CCI edit check: 99214 + 20610 — modifier -25 needed
05Medical necessity: M54.5 + 72148 — conservative tx required
06Auto-correction applied: modifier -25 → CPT 99214
072 issues flagged with recommendations generated
08Validation complete — 1.2s processing time
11.8%
Average Denial Rate
2024 — MDaudit
$25.7B
Annual Adjudication Spend
Premier Analysis
54%
Denials Overturned on Appeal
Plan pays after wasted processing
15–20%
Claims Still Need Manual Review
At most U.S. health plans
HOW IT WORKS

Upstream Intelligence Layer

The platform intercepts claims after the clearinghouse and before your adjudication engine. Three layers of intelligent validation in under 2 seconds.

STEP 01

Parse & Validate

Inbound EDI 837P and 837I files are parsed against X12 5010 standards. Every segment, loop, and data element is structurally validated.

STEP 02

Cross-Reference Rules

Each claim is validated against payer-specific adjudication rules, CCI edits, MUE limits, medical policies, and benefit configurations via RAG.

STEP 03

Correct & Recommend

Simple issues are auto-corrected. Complex cases get detailed recommendations with supporting evidence, denial probability, and corrective actions.

DENIAL TRIGGERS IDENTIFIED

What the Agent Catches

The platform catches the issues that cause 85% of preventable denials across all major payers.

Missing or Incorrect Modifiers

Modifier -25, -59, -26, laterality modifiers. Auto-corrected when deterministic.

Prior Authorization Gaps

Missing, expired, or mismatched auth numbers. Retroactive auth windows flagged.

CCI Edit Violations

Bundling conflicts, MUE limit breaches, and procedure combination rules.

Medical Necessity

Diagnosis-procedure mismatch against payer medical policies and LCD/NCD criteria.

Eligibility Mismatches

Real-time 270/271 verification. COB conflicts, terminated coverage, benefit limits.

Coding Errors

Invalid CPT/HCPCS/ICD-10 codes, place of service mismatches, NDC omissions.

WHY MONAKESAI

How We Compare

Traditional tools are either reactive (post-denial) or static (rules-based). We're proactive, intelligent, and adaptive.

CapabilityRPA ToolsRules-Based ScrubbersPost-Denial PlatformsMONAKESAI
Pre-submission validation—Partial—✓
Dynamic rule adaptation———✓
Auto-correction—Limited—✓
AI-powered reasoning——Partial✓
Payer-specific logic—StaticPartial✓
Medical necessity analysis———✓
Real-time processing (<2s)—✓—✓
Continuous learning loop———✓
IMPACT FOR HEALTH PLANS

Measurable Outcomes

↑

Auto-Adjudication Rate Increase

More claims pass through without human intervention. Exact improvement validated during 12-week pilot with your claims data.

↓

Reduction in Manual Review Queue

Fewer claims pend to manual queue. Staff reallocated to complex case management and audit response. Reduction measured during pilot.

Fewer FTEs

Examiner Capacity Freed

More claims auto-adjudicate. Fewer examiners needed for routine review. Redeploy to complex cases, fraud prevention, or audits.

ROI MODEL

Financial Impact — Illustrative

Projected annual impact for a mid-size health plan processing 500,000 claims per month. Exact improvements validated during pilot.

Before MONAKESAI

Auto-adjudication rate81%
Claims to manual queue95,000/month
Examiners required~113 FTEs
Manual adjudication cost$1,900,000/month
Provider appeals to process~24,000/month
Appeals processing cost$1,560,000/month
Total Monthly Cost
$3.46M
Manual adjudication + appeals processing — $41.5M annually

After MONAKESAI

Auto-adjudication rateImproved*
Claims to manual queueReduced
Examiners requiredFewer FTEs needed
Manual adjudication costReduced
Provider appeals to processReduced
Appeals processing costReduced
MONAKESAI platform ($0.50–$1.00/claim)Varies by plan
Estimated Savings
Validated During Pilot
*Use the ROI calculator below with your actual plan data to model projected impact
ROI CALCULATOR

Model Your Savings

Enter your plan's numbers. Model the projected impact. Exact results validated during pilot.

Your Plan's Numbers
Claims Operations
500K
50,0002,000,000
81%
% of claims processed without human touch
60%95%
$20
Fully loaded examiner cost per manually reviewed claim
$10$35
40
Average throughput for manual adjudication queue
2080
$55,000
Fully loaded (salary + benefits + overhead)
$40,000$85,000
Denials & Appeals
12%
% of claims your adjudication system initially denies
3%25%
40%
% of denied claims where providers file an appeal
10%70%
54%
% of appeals where your plan reverses the denial
20%70%
Estimated Annual Savings to Your Plan
$20.8M
Monthly
$1.7M
ROI
4.61x
Examiners Freed
72 FTEs
Staffing Savings
$330,000/mo
MetricCurrentWith MONAKESAI
Manual Adjudication
Auto-adjudication rate81%93%
Claims to manual queue95K/mo35K/mo
Examiners required114 FTEs42 FTEs
Manual adjudication cost$1.9M/mo$700,000/mo
Denials & Provider Appeals
Claims denied60K/mo25K/mo
Provider appeals filed24,000/mo10,080/mo
Appeals overturned (wasted)12,960/mo5,443/mo
Appeals processing cost$1.6M/mo$655,200/mo
Platform Investment
MONAKESAI (@$0.75/claim)—$375,000/mo
Total Monthly Cost$3.5M$1.7M
Additional value not quantified above
Provider network retention (fewer disputes, faster payments), prompt-pay law compliance, reduced member grievances, improved STAR ratings for MA plans, and reallocation of freed examiner FTEs to complex case management or fraud prevention.
PLATFORM COMPATIBILITY

Integrates With Your Stack

REST API for real-time integration. SFTP for batch processing. Compatible with your existing infrastructure.

Core Admin Systems

TriZetto QNXT
TriZetto Facets
HealthEdge HealthRules
McKesson ClaimCheck
Cognizant CAPS

EDI & Clearinghouses

AXIOM (Cotiviti)
EDIFECS
Change Healthcare
Availity
Waystar

Integration Modes

REST API (real-time)
SFTP batch processing
270/271 eligibility
EDI 837P / 837I X12 5010
HIPAA-compliant

Start With a 12-Week Pilot

Structured deployment against a subset of your claims volume. Measurable success metrics: auto-adjudication rate improvement, manual queue reduction, denial prediction accuracy. Full ROI validation before commitment.