Axora agents retrieve real-time payer intelligence, evaluate claim context holistically, and surface risks before submission, not after rejection
Retrieves current payer guidance, contract logic, and adjudication signals using RAG-grounded intelligence
Agents evaluate documentation context, coding logic, and payer rules together as a coordinated decision
Submission risks are surfaced and routed for correction before the claim moves forward
Unlike traditional claim scrubbers that validate fields against static rule libraries, Codora evaluates the full claim context and surfaces submission risks earlier in the workflow.
Codora evaluates whether a claim will clear payer scrutiny before submission by analyzing documentation context, coding relationships, payer requirements, and adjudication behavior together.
Visit caps, exclusions, plan logic, mapped instantly
Mid-cycle rule shifts flagged in real time
Live prompts ensure cleaner, accurate front-office capture
Actionable signals and correction paths that surface inside the workflow — not buried in reports or dashboards
Eligibility & Benefits Intelligence
Payer Rule Intelligence
Documentation & Coding Alignment
Pattern Recognition & Drift Alerts
A 200-bed hospital kept seeing “coverage terminated” despite clean checks
Axora detected a mid-cycle shift in payer files and alerted the front office instantly
Coverage-related denials dropped within 30 days
A rehab centre scheduled sessions beyond the patient’s visit limits
Axora surfaced benefit-cap risks at the moment of scheduling
No denials for exceeded limits going forward
A multi-specialty hospital kept seeing “auth approved but benefit denied”
Axora matched auth rules with live benefit logic and flagged the mismatch early
The recurring denial loop stopped within two cycles
A diagnostics network faced denials for high-risk CPT × diagnosis combinations
Axora predicted these conflicts before verification ran
Claims were corrected upfront, avoiding downstream fallout
Traditional claim scrubbers check for formatting errors, missing fields, and basic code validity. They confirm that a claim is structurally complete. What they do not check is whether the clinical and billing information on that claim will hold up against the specific rules of the payer it is being submitted to. Payer-specific criteria like coverage policies, code combination rules, authorisation requirements, documentation expectations, sit outside the scope of a standard scrubber. Claims that pass scrubbing can still fail at the payer because the scrubber was checking the wrong things.
The most common missed conflicts fall into a few categories. Code combinations that are valid individually but not accepted together under a specific payer’s rules. Procedure codes submitted without the supporting diagnosis codes that payer requires. Authorisation references that are missing, expired, or do not match the service being billed. Fee schedule conflicts where the billed amount does not align with the contracted rate. These issues are not visible to standard scrubbers because they require payer-specific knowledge, not just code-level validation. They are also the issues that generate the most rework when caught after submission.
Codora reviews each claim against the specific requirements of the payer it is being sent to. This includes checking that the diagnosis and procedure codes are consistent with each other, that any required authorisation references are present and valid, that the documentation supports the services being billed, and that the claim meets payer-specific formatting and submission criteria. Where a conflict or gap is found, Codora flags it with a clear reason so the billing team knows exactly what needs to be resolved before the claim proceeds.
Different payers apply different rules to the same claim types. A procedure that requires specific supporting documentation for one payer may have different requirements for another. Codora applies payer-specific validation logic to each claim based on who it is being submitted to, so the review is relevant rather than generic. For health systems submitting across multiple payer environments, as is common across GCC markets. This means every claim is checked against the rules that actually apply to it rather than a generic ruleset that approximates payer requirements without reflecting them.
Most claim corrections are preventable. The coding conflict, the missing authorisation reference, the payer-specific documentation gap. These are all identifiable before submission if the right checks are in place. Codora runs those checks systematically so the billing team can resolve issues while the claim is still in the provider’s system. The alternative is a resubmission cycle, correcting the claim, reprocessing it, waiting for a second adjudication decision, that delays payment and consumes administrative capacity that could be spent elsewhere.