Introduction
Eligibility denials create costly rework after claims reach payers. This client story examines how targeted rules can catch coverage, payer routing, coordination of benefits, and Medicare-related issues before submission.
In June 2026, MedCare MSO deployed 15 production rules through Nomos AI. Within two months, billed claim volume increased 25%, while primary eligibility denials fell from 9.2 to 7.5 per 1,000 claims. The analysis estimates that 233 primary denials were avoided.
Key Takeaways
- Primary eligibility denials fell 18.8%, from 9.2 to 7.5 per 1,000 billed claims.
- Billed claim volume increased 25% during the same period.
- Approximately 233 primary denials were avoided in June and July, based on the baseline rate.
- July’s denial rate reached 6.4 per 1,000 claims, about 31% below baseline.
- Overall eligibility denial rates improved 6.6%, while secondary and tertiary rates remained nearly flat at 14.0 to 14.2 per 1,000 claims.
- Several primary denial categories improved, but patient identification denials increased, highlighting the next area for improvement.
- The 15-rule inventory addressed eligibility, payer routing, coordination of benefits, Medicare risks, and related claim edits.