Built on CMS data, not guesswork
MedicalClaim.ai cross-references 8 federal datasets to check your claims before you submit them. Every denial risk score, bundling flag, and reimbursement estimate traces back to published CMS source files.
Data sources
Every table links back to a published CMS or X12 dataset. No proprietary scraping, no estimates.
| Dataset | Source | Edition | Records | Used for |
|---|---|---|---|---|
| ICD-10-CM | CDC / CMS | FY 2026 | -- | Diagnosis code validation, medical necessity checks, LCD/NCD coverage mapping |
| CPT / PFS | CMS Physician Fee Schedule | CY 2026 Q1 | -- | Procedure codes, work/PE/MP RVUs, facility and non-facility Medicare rates |
| HCPCS Level II | CMS HCPCS | 2026 | -- | DME codes, supply codes, drug administration J-codes, temporary codes |
| NCCI PTP Edits | CMS NCCI | Q1 2026 | -- | Procedure-to-procedure bundling conflicts, modifier indicators |
| NCCI MUE | CMS NCCI | Q1 2026 | -- | Medically unlikely edits, per-line unit maximums, adjudication type |
| MS-DRG | CMS IPPS | FY 2026 | -- | Inpatient DRG weights, geometric/arithmetic mean LOS, relative weights |
| CARC | X12 / WPC | Current | -- | Claim Adjustment Reason Codes, denial reason decoding, appeal trigger mapping |
| Place of Service | CMS POS | Current | -- | POS code validation, facility/non-facility rate selection |
How claim checks work
Code validation
Your CPT/HCPCS and ICD-10 codes are checked against the current CMS code tables. We verify the code exists, is active, and return its description, RVUs, and Medicare rates.
Bundling and edit checks
We run your procedure code through the NCCI Procedure-to-Procedure edits to flag bundling conflicts. MUE limits are checked against your units. Modifier indicators show whether a modifier can override the edit.
Medical necessity
Your CPT-ICD pair is matched against LCD and NCD coverage determination data. We check both the covered and non-covered ICD-10 lists from CMS Local Coverage Determinations to assess whether the diagnosis supports the procedure.
Payer simulation
Denial risk is modeled per payer using a 4-tier engine: exact match lookups for known high-risk combinations, category-based rules, code-type heuristics, and baseline payer profiles with documented denial rate data.
Reimbursement estimate
Medicare rates are calculated from PFS RVUs times the CY 2026 conversion factor ($33.5675). Commercial estimates apply payer-specific multipliers. All figures are pre-adjustment and should be used as benchmarks only.
Appeal framework
When a claim has elevated denial risk, we generate an appeal strategy matched to the specific denial reason. Frameworks include timeline, required documentation, and step-by-step instructions drawn from CMS appeals process guidelines.
Limitations
- Not a clearinghouse. MedicalClaim.ai performs pre-submission analysis only. We do not submit, adjudicate, or process claims.
- Medicare as baseline. Reimbursement estimates use CMS PFS data. Commercial payer rates vary by contract and are modeled, not actual contracted amounts.
- Coverage data is partial. LCD/NCD coverage mappings are imported from published CMS data. Not all LCD determinations are represented. A "supported" result does not guarantee payment.
- Payer models are probabilistic. Denial risk scores are based on publicly available payer data and known behavioral patterns. They do not reflect your specific contract terms.
- Not medical or legal advice. This tool assists revenue cycle professionals with claim preparation. It is not a substitute for professional medical billing guidance.