Healthcare Billing & Denial Resolution Agent

Softree proposed an AI Healthcare Billing & Denial Resolution Agent using Amazon Bedrock, Amazon Bedrock AgentCore, and retrieval-augmented generation (RAG). The solution connects approved claims systems and document repositories with payer guidance to support structured investigations and route unresolved cases to billing specialists.

• Claim context gathering: The agent retrieves authorized claim history, denial codes, previous communications, and supporting documents to establish a complete case context.
• Payer requirement retrieval: RAG searches approved payer policies, billing guidance, and documentation requirements relevant to each claim.
• Denial classification: The agent proposes a denial category, identifies missing or inconsistent evidence, and provides a summarized rationale with source references.
• Follow-up preparation: The solution drafts document requests, payer follow-ups, and appeal preparation notes for billing specialists to review.
• Specialist routing: Cases involving conflicting evidence, complex policy questions, or approaching deadlines are routed to authorized billing staff.
• Controlled operations: Permissions, human review, monitoring, and audit logging govern sensitive claims data and downstream actions.