Infrastructure for Medical Bill Review & Automated Adjudication

Automated adjudication of medical bills requires machine-executable rules: fee schedules by state and payer type, CPT/ICD-10 coding guidelines, unbundling logic (CCI edits), usual-and-customary thresholds, and utilization review criteria. These cannot remain as general policy text—they must be formalized as queryable decision logic. When adjudication rules are documented at L3 but not machine-readable, the system requires human override for edge cases that should be automatable, defeating the cost-reduction objective.

Medical bill review requires systematic capture of UB-04 and HCFA-1500 forms, itemized statements, and associated diagnosis and procedure codes through defined intake workflows. Template-driven capture ensures every bill submission includes the structured fields (bill type, rendering provider NPI, procedure codes, billed amounts) the adjudication engine needs. Without consistent capture templates, bills arrive in incompatible formats that block automated processing.

Automated adjudication requires formal ontology defining relationships between procedure codes, diagnosis codes, fee schedules, provider types, and coverage categories. Without explicit mapping of CPT.93000 (ECG) as a bundled service that cannot be billed separately from an E&M visit under NCCI edits, the system cannot detect unbundling. Entity relationships—Provider.type → FeeSchedule → ProcedureCode.allowed → CoverageCategory—must be formally defined for rule execution.

Medical bill adjudication must query fee schedule databases, state-mandated reimbursement schedules, coverage terms from the policy admin system, and provider credentialing data via API. HIPAA constraints restrict access but don't prohibit it—controlled API access with appropriate authorization satisfies both security and operational requirements. Batch or manual access (L2) creates payment cycle delays that generate regulatory prompt-payment violations.

Fee schedules, state regulations, and CPT/ICD-10 code sets update annually or quarterly. The bill review system requires event-triggered updates when these change—new CPT codes taking effect January 1 must be in the system by December 31, not after a quarterly review cycle. Without event-driven maintenance, the adjudication engine applies prior-year fee schedules and rejects valid new procedure codes.

Medical bill adjudication must integrate the claims system (coverage and reserve data), policy admin (benefit limits, deductibles), fee schedule databases, provider directories, and payment processing via API-based connections. Each system contributes essential adjudication context: coverage terms from policy admin, allowed amounts from fee schedules, and provider NPI validation from the provider directory. Without these connections, adjudicators manually verify each data point.