How to build a Claim Denial Prevention Agent
An AI-powered RCM analyst that automatically triggers when new claims or remittance files arrive in S3, queries historical data from Snowflake, assesses denial risk or root causes, and routes findings to Microsoft Teams and Epic FHIR workqueues.
Challenge
Healthcare billing teams spend countless hours manually reviewing claims, investigating denials, and coordinating follow-ups across disconnected systems—leading to delayed reimbursements and revenue leakage.
Industry
Healthcare
Department
Finance
Customer Success
Integrations
Epic FHIR
Microsoft Teams
This automated workflow transforms how healthcare organizations handle revenue cycle management by combining real-time event detection with AI-powered analysis.
How It Works:
Automatic Trigger — The workflow activates instantly when claims or remittance files are uploaded to an S3 bucket via SQS notifications, eliminating manual monitoring.
Contextual Data Retrieval — The system queries your Snowflake database to pull relevant context including prior denials for the member/provider, payer policy mappings, and historical approval/denial statistics.
AI-Powered Analysis — A GPT-powered analyst reviews the claim data to determine whether this is a pre-submission review or post-denial investigation. It calculates denial risk scores, identifies primary drivers with supporting evidence, and generates specific corrective actions.
Multi-Channel Routing — Results are automatically distributed to:
An Output for immediate visibility
Microsoft Teams to notify the RCM channel in real-time
Epic FHIR to create work items directly in the provider's billing workqueue
Key Benefits:
Reduces manual claim review time
Catches denial risks before submission
Accelerates post-denial root cause analysis
Ensures consistent, evidence-based recommendations
Keeps billing teams informed via Teams notifications
Integrates directly with Epic for seamless workflow handoff
