Healthcare Claims Agent

Last Updated: October 25, 2026

The Healthcare Claims Agent is a Vasion-built agent that helps you find out why a payer declined a medical insurance claim and what to correct before you resubmit it. You provide the claim materials in a chat, and the agent returns a written analysis and a proposed revised CMS-1500 claim form. You review the results and resubmit the claim yourself.

This feature is in beta. Capabilities, configuration, and availability may change as development continues. Contact your Vasion representative with feedback to help shape this feature.

Key Points

Review the following key points:

  • The agent analyzes one declined claim at a time and identifies one or more likely denial reasons.
  • The agent asks for missing information instead of making assumptions.
  • The agent returns an analysis report and a proposed revised CMS-1500 claim form that you download.
  • You can ask follow-up questions and add documents in the same chat.
  • The agent proposes changes only. It does not submit or resubmit claims.

How the Healthcare Claims Agent Works

You start a chat with the agent and upload your claim materials. The agent checks that the materials include the required details, such as the denial reasons, procedure codes, and dates of service. If details are missing, the agent asks you for them. When the materials are complete, the agent analyzes the claim, verifies codes and provider identifiers in public registries, and returns its results for your review.

Healthcare claims agent process flow diagram.

Claim Materials

You can provide the following materials:

  • Original claim: The insurance claim as submitted, such as a CMS-1500 form.
  • Denial documentation: A denial notice, Explanation of Benefits (EOB), or Electronic Remittance Advice (ERA).
  • Physician visit notes: Visit notes or a clinical encounter summary. The agent uses the notes to evaluate medical necessity and recommend more specific diagnosis codes.

Analysis Report

The report lists the likely denial categories, a plain-English explanation of each, missing or questionable items, and recommended actions for you to take. The report separates confirmed facts from recommendations.

Proposed Revised Claim

The agent generates a proposed revised CMS-1500 claim form that includes its suggested corrections, such as updated diagnosis codes, provider identifiers, modifiers, and resubmission notes. The form is labeled as an agent-generated proposal. Verify every change before you use the form.

Code and Provider Verification

The agent checks diagnosis codes against the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code set and verifies National Provider Identifiers (NPIs) in the NPI Registry. The agent sends only codes and identifiers to these public registries. It does not send patient information or claim text.

Follow-Up Questions

The agent keeps the claim materials, its analysis, and the conversation in the chat. You can ask a follow-up question, such as why a specific line item was denied, without uploading the materials again. You can also upload more documents, and the agent adds them to the materials you already provided. If you ask the agent to analyze a different claim, the agent keeps the new claim separate from the earlier one.

Requirements

Review the following requirements:

  • Your organization has access to the Healthcare Claims Agent. If the agent does not display on the Agents page, contact your administrator.

  • Permission to access Agents.

  • Creator role.
  • Claim materials in PDF, JSON, or DOCX format.

Other Relevant Details

Data Retention

The agent keeps your chat, uploaded files, and generated files for three days. After that time, the agent might no longer have your claim materials. If this happens, the agent asks you to upload the materials again.

Limitations

The Healthcare Claims Agent does not do the following:

  • Submit or resubmit claims, or interact with payer portals.
  • Connect to electronic health record (EHR) systems or clearinghouses.
  • Process more than one claim at a time.
  • Provide medical or legal advice, or make formal medical necessity determinations.

Next Steps

Refer to the following: