Problem Statement

Billing teams managing insurance claims and self-pay invoices spend significant time on manual, repetitive work:

1. Pre-submission checking — manually verifying claim completeness and correct coding before sending to a payer.
2. Denial investigation — looking up what a denial reason code means and deciding what to do next.
3. Appeal writing — drafting formal appeal letters from scratch for each denied claim.

These tasks delay cash flow, introduce errors, and consume expert time that could be spent on higher-value work.

Solution

A Zango-based billing platform that embeds three AI agents directly into the billing workflow:

• ClaimValidator fires automatically when a claim is submitted, checking completeness and suggesting codes.
• DenialAnalyzer and AppealDrafter fire concurrently (in parallel) the moment a claim is denied, producing a root-cause analysis and a ready-to-send appeal letter simultaneously.

All AI outputs appear on the Claim’s AI Insights tab, available to billing staff within seconds of each workflow transition.

User Stories

1. As BillingStaff, I want to create a Patient record with name, date of birth, contact info, and insurance details, so that I have a single source of truth for each patient before creating claims or invoices.
2. As BillingStaff, I want to select an InsurancePayer when creating a Claim, so that the payer routing is captured at claim creation.
3. As BillingStaff, I want to add ClaimLineItems (CPT code, description, quantity, unit price) to a Claim, so that all billable procedures are documented before submission. [DEFERRED 2026-07-19] The ClaimLineItem model and its totals invariant exist, but there is no user-facing UI to create/edit line items yet — deferred past this pass given time remaining. Claim integrity work in this pass covers total_amount and diagnosis_codes validation only; it does not add a "≥1 line item required" check, since there's currently no real path for a user to create one.
4. As BillingStaff, I want to submit a Claim with one click, so that it transitions from Draft to Submitted and the ClaimValidator agent runs automatically in the background.
5. As BillingStaff, I want to see the ClaimValidator’s completeness score, flagged issues, and code suggestions on the Claim detail page, so that I can correct problems before the payer reviews the claim.
6. As BillingManager, I want to transition a Claim to “Under Review” or “Approved”, so that the claim lifecycle reflects the payer’s current status.