8Medicore trains on payer policy language, hospital documentation, and historical denial patterns to identify exactly why a claim was rejected — and builds the appeal that gets it paid.
*Illustrative targets based on industry benchmarks. 8Medicore is in early access — figures will be validated against live client data during pilot.
Every payer writes its own rules. Every plan reinterprets them. Billing teams are left manually decoding rejection codes against policy PDFs that change quarterly — and most denials that could be overturned are never appealed at all.
Hundreds of payers, thousands of plan variants — Medicare Advantage, commercial, Medicaid MCOs — each with its own medical necessity criteria, prior-auth thresholds, and documentation format. CPT/HCPCS bundling edits and LCD/NCD coverage determinations shift quarterly, often without clear notice to providers.
A clean appeal requires matching the exact denial reason code (CARC/RARC) to the governing policy clause, then citing it precisely. Most billing departments don't have headcount to do this at volume — so the backlog grows faster than it clears.
Industry benchmarks consistently show a large share of denied claims are never appealed at all — even first-level appeals with strong documentation. Every unappealed denial is realized revenue loss, not a deferred one.
8Medicore doesn't replace your billing team — it removes the manual research and drafting work, so your specialists spend their time approving and submitting, not searching.
Denial letters, EOBs, and payer correspondence are parsed automatically and matched to a denial reason category using CARC/RARC code mapping and NLP-based document classification.
A retrieval-augmented pipeline pulls the exact policy clause relevant to the denial reason and drafts an appeal grounded in that language — not a generic template.
Your specialists review, edit if needed, and submit. Every accepted or rejected appeal feeds back into the retrieval model, sharpening citation accuracy over time.
Each module works standalone or as part of the full pipeline, depending on where your team needs the most help first.
See which payers, plans, and denial codes are costing you the most — broken down by department, provider, and recoverability likelihood.
Generates a fully cited first-draft appeal letter referencing the specific payer policy clause, plan language, and clinical documentation tied to the denial.
A continuously updated index of payer medical policies, plan documents, and regulatory guidance — the foundation every appeal is grounded in.
No black box. Here's the actual pipeline 8Medicore is designed around — and why each layer exists.
Payer policies, LCDs/NCDs, and plan documents are chunked and embedded into a vector index. Denial reason text is matched against this index, not against a static lookup table — so the system adapts as policies update.
An LLM reasons over the retrieved clause set plus the claim's clinical documentation to determine whether the denial is contestable, and on what specific grounds — medical necessity, coding, timely filing, or coverage.
Every submitted appeal's outcome — paid, partially paid, or upheld denial — is logged and used to recalibrate retrieval relevance and reasoning confidence for similar future cases.
Payer policy changes quarterly, sometimes more often. A model trained end-to-end on historical denials would go stale the moment a payer updates a coverage determination. A retrieval-grounded approach lets us refresh the policy index independently of the reasoning model — accuracy keeps pace with policy, not with retraining cycles.
No appeal is auto-submitted. Every draft routes to a billing specialist for review before it leaves the building. The model's job is to remove the research and first-draft burden — not the judgment call, and not the accountability.
*Projected targets for the pilot phase. 8Medicore has no live production deployments yet — these are model-design goals we will report against transparently as pilots begin.
8Medicore has not yet onboarded production clients. The quotes below represent the kind of outcome our model is designed to produce — they will be replaced with real pilot testimonials as they come in.
"Our billing team stopped re-reading the same payer policy PDFs every week. The first drafts are already 80% of the way there."
Revenue Cycle DirectorTarget persona: Mid-size health system"We finally have visibility into which payers are denying us the most, and why — not just a pile of rejected claims."
HIM DirectorTarget persona: Regional hospital"The appeal citations actually point to the right clause. That used to take our specialists an hour per claim."
Billing Operations LeadTarget persona: ASC networkWe are not yet certified. We are building 8Medicore's infrastructure to HIPAA, SOC 2, and HITRUST standards from the ground up, and will not onboard production PHI until these are in place.
Data handling and access controls designed against HIPAA safeguards from initial build.
In ProgressFormal audit planned ahead of first production pilot onboarding.
PlannedTargeted post-pilot, aligned with enterprise procurement requirements.
RoadmapAll claim and policy data encrypted end-to-end across the pipeline.
Built-InHigh imaging-edit denial complexity, fast-cycle appeals.
Procedure-heavy claims, strict medical necessity review.
Bundling edits and post-surgical documentation gaps.
Frequent authorization-related denials, ongoing-care appeals.
Visit-cap and progress-note documentation disputes.
High claim volume, panel-bundling and frequency denials.
Coverage-criteria and medical-necessity heavy category.
Step-therapy and controlled-treatment authorization disputes.
Recertification and homebound-status documentation cases.
Cross-benefit (medical/dental) coordination denials.
We're onboarding a small group of pilot hospitals before general availability. Tell us about your denial volume and we'll show you what the model would flag in your data.
Request a Pilot Conversation