New Insurance Billing Case-monetization router

Every completed case is preloaded by your techs and reading neurologists, then routed to the revenue channel that recovers the most: an out-of-network insurance claim (IDR feeder), a government in-network claim, or a hospital technical-fee invoice.

Cases to route

this week

$1.94M

Commercial OON → IDR feeder

23 claims · 99% of book

⏱ Two-clock exposure

$312,400 recoverable at IDR-clock risk

3 claims inside the IDR initiation window - a missed clock is lost money.

IDR window · 3 claims ≤ 4 biz days

Timely filing · 2 claims ≤ 5 days

Hospital tech-fee invoices

→ routes to portal · ~33%

Supervisor oversight

Supervisor viewSupervisor view - billers don't see this.

Claims worked today (team)

4:21

Avg time / claim

78%

Team active time

Dead-time flag

Biller	Claims today	Avg time/claim	Active %	Claims/hr	Dead time
Sample, Dana · top today	34	3:12	91%	8.4	Low
Demo, Alex	29	3:48	88%	7.1	Low
Mockdata, Sam	21	4:40	79%	5.6	Moderate
Example, Priya	12	9:26	54%	2.9	⚑ High

Select cases to review, approve, or route in bulk

Channel: Commercial OON → IDR feeder Government in-network Hospital technical-fee invoice

Patient	Claim / DOS	Component	Payer	Channel	Charges	Clock	Status
Testcase, Alice PID 100001	1000001 10/20/2025	PRO + TECH	United Healthcare ◆ Out-of-network	◆ Commercial OON → IDR	$48,087.92	⏱ File in 5d · IDR after	▲ Needs review	Open →
Mockdata, Ray PID 100002	1000007 10/18/2025	PRO ONLY	Aetna ◆ Out-of-network	◆ Commercial OON → IDR	$53,905.00	✓ Filing OK	✓ Ready to file	Open →
Sample, David PID 100004	1000002 10/20/2025	PRO + TECH	Humana ◆ Out-of-network	◆ Commercial OON → IDR	$61,240.00	⏱ IDR in 3d	▲ Needs review	Open →
Demo, Charles PID 100005	1000003 10/14/2025	PRO ONLY	BCBS ◆ Out-of-network	◆ Commercial OON → IDR	$52,030.00	⏸ Held	⏸ Waiting on tech	Open →
Testcase, Bruce PID 100009	1000009 10/09/2025	PRO + TECH	Cigna ◆ Out-of-network	◆ Commercial OON → IDR	$41,880.00	⏱ IDR in 2d	◆ IDR-eligible	Open →
Specimen, Tom PID 100007	1000005 06/18/2025	TECH ONLY	Medicare Government · can't go OON	▣ Hospital tech-fee invoicefacility contract · not an insurance claim	$34,290.00	-
Sample, Nora PID 100008	1000008 06/12/2025	TECH ONLY	Medicare Government · can't go OON	▣ Hospital tech-fee invoicefacility contract · not an insurance claim	$29,140.00	-
Example, Marta PID 100006	1000004 06/18/2025	PRO + TECH	Mercy Care AZ Medicaid HMO · in-network	● Government in-networkpays low · no OON path	$30,695.01	✓ Filing OK	Files as-is (low pay)	Details →

/Testcase, Alice

Testcase, Alice

PID 100001Claim 1000001 DOS 10/20/2025Component Pro + Tech Payer United Healthcare◆ Out-of-network

▲ Review in progress

Park this claim - what are you waiting on?

⏸Parked. · saved at your spot. Open another patient and come back anytime.

95% preloaded from case #1000001 - techs entered demographics & insurance, the reading neurologist's report set the coding. Review each section and approve; edit only what's wrong.

Patient

Preloaded by tech

Name

Testcase, Alice

Sex

Female

DOB

08/29/1971

Address

1200 Sample Ridge Ln, Springfield, ST

Phone

555 555 0142

EMR status

Inpatient

SSN

•••-••-4407

Relation to insured

Self

Insurance & Benefits

Preloaded by tech · VOB 10/14/2025

Type

Commercial

Payer

United Healthcare

Policy #

2W76y49mp67

Network

Out-of-network

Verification of benefits (VOB) status

✦ AIflagged by AI · via USMON MCP

⚠ Stale - last verified 10/14/2025 (older than UHC's OON re-verify window at filing)

AI flag: benefits on file exceed United Healthcare's re-verification window for OON claims. Re-check eligibility & OON benefits before filing so the QPA on record is current.

In-network (not applicable)

Status: No in-net contract
Reason: OON by design

◆ Out-of-network - NSA applies

OON benefits: Active
QPA on file: ~$7,697
Timely filing: 90 days
NSA protection: Yes · IDR-eligible

Channel: Commercial OON → IDR feeder. Charges set above QPA by design. Expect a below-QPA remittance - the recovery happens in follow-up via NSA negotiation and IDR (Arbitration). Both clocks tracked in the rail.

Procedure & Diagnosis

From reading neurologist's report · AI-extracted

Procedure monitored

Anterior cervical discectomy & fusion, C5–C7

Place of service

21 - Inpatient Hospital

Principal diagnosis (ICD-10)

✦ AIAI-suggested principal code · via USMON MCP

M50.121 - Cervical disc disorder with radiculopathy, C6–C7

Extracted from the reading neurologist's report: "…moderate radiculopathy at the C6–C7 level with corresponding SSEP/MEP changes." Confidence 0.94. Placed first so the service-line Dx pointers resolve correctly.

Supporting diagnoses (prefilled)

M50.120 · M54.12 · G89.18

Coding & Service Lines

From reading neurologist's report

#	CPT	Mods	Units	Dx	Charge	Rendering (24J)	Description
1	95887	26	1	A	$361.25	Sample, Alan MD ✦ AI	Needle EMG, non-extremity
2	95909	26	1	A	$849.15	Sample, Alan MD	Nerve conduction, 7–8 studies
3	95937	26	4	A B	$6,332.50	Sample, Alan MD	Neuromuscular junction test
4	95938	26	6	A B	$11,900.01	Sample, Alan MD	SSEP upper & lower
5	95939	26	3	A	$17,850.01	Sample, Alan MD	MEP upper & lower
6	95955	26	1	A	$10,795.00	Sample, Alan MD	EEG during surgery

Units - line 4 (95938, SSEP)

✦ AIAI-derived from monitoring minutes · via USMON MCP

6 units

Derived from 268 minutes of intraoperative SSEP monitoring on the tech report (≈45 min/unit). Confirm it matches the documented time.

Rendering provider - line 1 (95887), Box 24J

✦ AIAI-matched from report signature · via USMON MCP

Sample, Alan MD - NPI 1000000048

Line 1 had no rendering provider. AI matched the signing neurologist from the reading report against the NPI registry. Confidence 0.97.

OON pricing applied: charges set at the client's OON fee schedule (≈6× QPA). Units derived from 268 min of monitoring on file. Charged $48,087.92 total.

Billing & Provider

Preloaded

Billing provider (Box 33)

Demo Neurophysiology LLC

NPI (33a)

1000000017

Tax ID

12-3456789

Service facility (Box 32)

Sample Specialists Hospital, Springfield ST

Facility NPI

1000000032

Signature

On file - Sample, Alan MD

Referring (Box 17)

A. Sample, M.D. - 1000000048

Taxonomy (24J)

2084N0400X

✦ AI fields to confirm

AI proposes, you decide - nothing files unconfirmed.

Claim review

Approve what's correct. Fix the exceptions.

0 of 5 sections reviewed0%

⏱ Clocks - never miss

Timely filingUHC · 90-day window

5d left

NSA negotiation / IDROpens once the OON remittance posts

pending file

Highlighted AI fields 4

✦

Stale VOB flagInsurance & Benefits

→

✦

Principal ICD-10 (M50.121)Procedure & Dx

→

✦

Derived units - 95938Coding & Lines

→

✦

Matched rendering providerCoding & Lines

→

Review & approve 0/5

○

PatientPreloaded by tech

○

Insurance & BenefitsTech · 1 AI field

○

Procedure & DxReport · 1 AI field

○

Coding & LinesReport · 2 AI fields

○

Billing & ProviderPreloaded

Validation - automatic ✓

✓

NPI, charges, Dx pointers, POS, ICD-10, signature all valid

Reviewed continuously - 6 events logged to audit trail.

Ongoing - Claim Follow-Up

Filed claims being worked: payments, out-of-network underpayments, and arbitration handed off to Arbitration.

$1.41M

Outstanding A/R

214 open claims

$386k

Collected this month

▲ 18%

$612k

In arbitration → Arbitration

38 OON claims

⏱ IDR-clock exposure

$248,000 aged > 90 days

11 OON claims at an IDR deadline - route to Arbitration before the window closes.

IDR initiation · 4 claims ≤ 4 biz days

Negotiation · 7 claims open

Patient	Claim / DOS	Payer	Channel	Charged	Collected	Balance	Aged	IDR state	Status
Sample, David PID 100004	1000002 10/20/2025	United Healthcare ◆ Out-of-network	◆ OON → IDR	$57,420.00	$0.00	$57,420.00	31d	Eligible	▲ ERA ready to post	Open →
Demo, Charles PID 100005	1000003 10/14/2025	Aetna ◆ Out-of-network	◆ OON → IDR	$61,240.00	$9,210.00	$52,030.00	38d	◆ In IDR · negotiating	Sent to Arbitration	Open →
Example, Marta PID 100006	1000004 06/18/2025	Mercy Care AZ MCD HMO · in-network	● Gov in-net	$30,695.01	$30,695.01	$0.00	6d	N/A	✓ Paid in full	Open →
Specimen, Sara PID 100010	1000005 06/18/2025	UHC ◆ Out-of-network	◆ OON → IDR	$36,432.51	$2,140.00	$34,292.51	71d	Underpaid	✕ Denied - appeal	Open →

/Testcase, Alice

Testcase, Alice

Claim 1000001DOS 10/20/2025 Payer United Healthcare◆ Out-of-networkEntity Demo Neurophysiology LLC

▲ ERA ready to post

Activity timeline

✦

Tennr VOB WorkerAutomated10/14 04:46 PM

Per face sheet - INS: United Healthcare · OON · benefits active. VOB complete.

↑

Clearing HouseEDI10/21 09:02 AM

Claim 1000001 (Pro + Tech) submitted to sshftp.iirmed.com · 837P batch.

✓

Clearing House277CA10/22 06:14 AM

Payer acknowledged - claim accepted into adjudication.

Payments & posting

No remittance posted yet. The UHC 835 has arrived in your clearinghouse inbox -
post it to reconcile against the service lines.

CPT	Mod	Charged	Allowed	Ins paid	ANSI	Balance
95887	26	$361.25	$92.40	$73.92	UCR	$287.33
95909	26	$849.15	$210.10	$168.08	UCR	$681.07
95937	26	$6,332.50	$1,040.00	$832.00	IDR	$5,500.50
95938	26	$11,900.01	$1,985.00	$1,588.00	IDR	$10,312.01
95939	26	$17,850.01	$2,810.00	$2,248.00	IDR	$15,602.01
95955	26	$10,795.00	$1,560.00	$1,248.00	IDR	$9,547.00
Totals		$48,087.92	$7,697.50	$6,158.00		$41,929.92

✦

Underpayment detected - not a denial. UHC paid $6,158 on $48,088 charged (≈13% of billed), below the qualifying payment amount on an out-of-network claim. This is IDR-eligible under the No Surprises Act. Neurology/neuromuscular IDR awards have averaged 12–17× the QPA. Recommend opening the negotiation window and routing to Arbitration.

AI proposes, you decide - logged to audit trail.

Documents - proof bundle

✓Verified BenefitsVOB10/14/25

📄Ext Reader Report - Sample, Alan MDReader10/15/25

📄Ext Tech ReportTech10/15/25

📄Face SheetFace sheet10/15/25

🧾CMS-1500 - Claim 1000001CMS 150010/20/25

📑UHC EOB / remittanceEOB12/02/25

💬Ext Chat logChat10/15/25

IDR & Arbitration

◆ No Surprises Act - eligibility & arbitration

Eligibility

OON · IDR-eligible

Underpaid balance

QPA (as received)

Est. IDR potential

Routing to Arbitration hands off a complete IDR case packet - claim, service lines, QPA, CARC/RARC, and the selected proof documents - over the USMON↔Arbitration MCP. Arbitration runs the negotiation and arbitration; USMON stays the system of record.

⏱Open negotiation started. 30 business days to negotiate · IDR initiation window (4 biz days) opens after. Arbitration is tracking the clock.

Folders

Client & entity folders, saved batches, and archived cases. Out of scope for this demo build.

Reports

Recovery by channel, IDR win rate, aged-A/R, and clock-exposure trend. Out of scope for this demo build.

Manage

Payer rules, OON fee schedules, client routing rules, and user permissions. Out of scope for this demo build.

	24F · Charges	Description
1		Needle EMG, non-extremity
2		Nerve conduction, 7–8 studies
3		Neuromuscular junction test
4		SSEP, upper & lower
5		MEP, upper & lower
6		EEG monitoring during surgery
Total charge (Box 28)	$48,087.92