Editorial Policy

Data Sourcing

MedicalClaim.ai builds its rules engine from publicly available data sources:

• CMS Physician Fee Schedule: Reimbursement rates, RVUs, and geographic adjustments published annually by CMS.
• NCCI Edits: Correct Coding Initiative edits for bundling and modifier validation.
• Payer Policy Bulletins: Clinical policy documents published by Medicare, UHC, Aetna, and BCBS.
• OIG Work Plans: Audit targets and enforcement priorities published by the Office of Inspector General.

Validation Process

Rules are validated against published payer documentation. Confidence scores reflect the specificity and recency of the underlying data. Category-derived estimates are clearly flagged as lower-confidence projections.

Limitations

Our rules engine provides estimates, not guarantees. Actual claim outcomes depend on documentation quality, local coverage determinations, and payer-specific adjudication processes that cannot be fully modeled.

For questions about our methodology, contact editorial@builtfor.ai.