HealthcareFinance
Claim denial. Prevented, not appealed.
Cross-checks a claim against payer remittance history and known denial patterns before submission, flagging denial risk and the specific reason — before the claim is filed, not after it bounces. Built for revenue-cycle teams submitting hundreds of claims a week.
14 cited fields per claim. Built on Sphere AI Foundry.
denial_prevention — claim #CLM-80217LIVE
00:00Ingest → claim, payer Aetna, CPT 99214read
00:02Coding check → modifier missing for bundled serviceflagged
00:04Payer pattern → 3 similar denials from this payer in 90 daysflagged
00:06Eligibility check → coverage active on date of servicepassed
00:07Disposition → Route to billing, 2 flags before submissionrouted
review time 8sfields cited 14/14billing sign-off required
Organizations around the world trust us
Built on Sphere AI Foundry·Checked against payer patterns·21 years, 300+ clients
Manual pre-submission review doesn't scale with claim volume
A single claim review means a biller checking coding, modifiers, and eligibility against what this specific payer has denied before — a pattern usually held in someone's memory of past rejections, not a system. At low volume that's manageable. Across hundreds of claims a week, it's the reason the same denial reason repeats for months before anyone connects the dots.
77%
fewer denials on flagged claim types vs. no pre-check
14
fields extracted & cited per claim
100%
of denial-risk flags traceable to a payer pattern or coding rule
Claim in, cited risk flag out
Four steps, every one logged and citable back to the payer's own history.
01
Ingest
Reads the claim directly from your systems
Claim, coding detail, and eligibility status — read from your practice management or billing system. No separate upload step.
Source claim
CLM-80217 — Aetna, CPT 99214
02
Match against payer patterns
Every line checked against payer denial patterns
Coding, modifiers, and eligibility — each checked against this payer's documented denial history and current coding rules, not a generic scrubber.
Example query
"Has this payer denied this CPT/modifier combination before?"
03
Cite every flag
No flag without a citation
Each flag links back to the exact payer remittance history or coding rule — the citation travels with the finding, not as a separate lookup.
Cited finding
Missing modifier 59 for bundled service — this payer has denied the same combination 3 times in 90 days.
cited to payer remittance history, 3 denials in 90 days04
Classify & route
One disposition, one consolidated fix list
The agent returns Clean, Flagged, or High Risk, with a consolidated fix list routed to billing before the claim is submitted.
Disposition
Clean claimFlagged — fixable ✓High denial risk
14 fields, every one cited
What the agent extracts from every claim it checks.
Denial-risk summary & disposition
Payer & plan verification
CPT/HCPCS coding & modifier check
Payer-specific denial pattern match
Eligibility & coverage verification
Prior authorization status check
Timely-filing deadline check
Consolidated fix list
Denial-reason citation
Billing review checklist
Typical inputs
What the agent reads, and what it connects to.
Documents
- Claim (CMS-1500 or UB-04) with coding detail
- Payer remittance and denial history
- Eligibility verification response
- Prior authorization records, where applicable
Systems
- Practice management / billing system
- Clearinghouse
- Payer portal
Is this the right fit?
Built for volume — not a one-off claim.
✓ Works best for
- Revenue-cycle teams submitting 200+ claims a week
- Practices standardizing pre-submission checks against payer-specific patterns
- Billing wanting every flag traceable to a real denial pattern
Too small for
- A single claim a biller can check faster than configuring the pattern match
- Replacing biller judgment on a genuinely novel coding scenario
- Payers with no denial history yet to learn from
Grounded in the payer's own pattern, not a black box
Compliance-first, the same standard every Sphere agent is held to.
The agent requires payer remittance history and current coding rules before it will return a disposition, and every check sits between claim creation and submission — never past it. Billing confirms every flagged claim before it goes out.
Flags reference the specific payer denial pattern or coding rule directly — the same audit-trail standard every Sphere agent on the Foundry is held to.
Prerequisites remittance history connected
Payer remittance history and current coding rules are required before a disposition is returned.
Human review required
Billing confirms every flagged claim before it's submitted — never fully autonomous.
Regulatory grounding pattern-cited
Flags reference the specific payer denial pattern or coding rule directly in every check.
Foundation Sphere AI Foundry
Access controls and audit trail configured here carry forward to every other agent you deploy.
Frequently asked
Does the Claim Denial Prevention Agent decide whether to submit a claim?
No. It flags denial risk and the specific reason for billing to review — billing still decides whether to fix and submit, hold, or appeal in advance.
What claim types does it support?
Professional (CMS-1500) and institutional (UB-04) claims out of the box. Additional claim types and payer rule sets can be added during onboarding.
How does it integrate with our practice management system?
It reads directly from your practice management or billing system, or your clearinghouse — no separate upload step required. Integration scope is confirmed during deployment planning.
Is every denial-risk flag traceable to a real pattern?
Yes. Every flag cites the specific payer denial history or coding rule it came from — there is no flag without a citation back to the source.
How is this different from a generic claim scrubber?
It's built specifically around each payer's own documented denial history, not a static, generic rule set. It runs on Sphere AI Foundry, so the access controls and audit trail configured here carry forward to other agents you deploy.
Hear from
our clientsHear from our clients
Lee Ebreo
VP of Engineering at Credit Ninja
These things would not have been achievable if we did not build our own in-house system and if we did not partner with Sphere to help us achieve our goals.
Selah Ben-Haim
VP of Engineering at Prominence Advisors
Our experience with Sphere and their team has been and continues to be fantastic. We keep throwing new projects at them, and they keep knocking them out of the park (including the rescue of a project that was previously bungled by another vendor).
Ben Crawford
Senior Product Manager at Enova Financial
I would expect to be delighted. It's been a really positive experience, working with Sphere, and I would expect you to have the same.
Mark Friedgan
CEO at CreditNinja
Sphere consistently prioritizes the needs of their clients, demonstrating both agility and teamwork. As an offshore team, they have been an integral part of our organization and we plan to continue growing with them.
René Pfitzner
Co-Founder at Experify
Sphere provided excellent full-stack development manpower to augment our team and help push our product forward. They are easy to work with, tech-savvy and proactive.
Bruce Burdick
Chief Information Officer at Integra Credit
We've been working with Sphere and its excellent consultants since our founding. I've found that they are true partners in the success of our business.
Jemal Swoboda
CEO at Dabble
The resources and developers that Sphere Software provides are skilled and have the required technical expertise, but more importantly, they have helped us build a culture of excellence within our team.
Arthur Tretyak
Founder and CEO at IntegraCredit
With Sphere, we were able to migrate in half the time it would take to train an additional FTE… and for a fraction of the cost. Our experience with Sphere has been exceptional.
Lee Ebreo
VP of Engineering at Credit Ninja
These things would not have been achievable if we did not build our own in-house system and if we did not partner with Sphere to help us achieve our goals.
Selah Ben-Haim
VP of Engineering at Prominence Advisors
Our experience with Sphere and their team has been and continues to be fantastic. We keep throwing new projects at them, and they keep knocking them out of the park (including the rescue of a project that was previously bungled by another vendor).
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Start here
See it on your own claims
Bring three real claims to the demo. We'll show the denial-risk check live — flags, citations, and the fix list, before submission.
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