Specialty Depth

Built for the specialties where one denied claim costs the most.

Complex CPT/ICD-10 pairings, implant documentation, unlisted codes, multi-level procedures — the cases where payer scrutiny is highest and manual pre-auth is slowest. Below, each specialty is shown the way it actually plays out: a denial, the gap that caused it, what PrismIQ filed, and the rule it wrote so it never recurs.

Orthopedics

01 — The scenario

High-value outpatient joint reconstruction ($24,000 claim) denied by a major national payer citing "Lack of Clinical Medical Necessity."

02 — The documentation gap

Payer scrubbers flagged incomplete conservative management documentation — a common automated denial tactic when physical therapy timelines and weight-bearing imaging are not explicitly cross-referenced.

03 — What PrismIQ did

PrismIQ's RAG engine parsed the patient's unstructured EHR charts, extracted the full conservative therapy timeline, and generated a Level 1 appeal cited directly against the payer's active clinical policy guidelines in under 45 seconds.

04 — The upstream rule it wrote

Pre-Submission Check: Automatically flags joint replacement claims missing mandatory pre-requisite therapy or imaging documentation before the claim ever leaves your practice.

Spine

01 — The scenario

Multi-level spinal fusion ($38,500 claim) underpaid by 40% due to unbundled hardware and add-on code denials.

02 — The documentation gap

Automated payer edits systematically stripped add-on instrumentation codes, leveraging complex hardware prior-authorization rules to withhold valid reimbursement.

03 — What PrismIQ did

Cross-referenced the payer's complex spinal policy rules, extracted supporting intraoperative notes, and built a targeted appeal that cited exact governing exceptions — recovering $15,400 in wrongfully denied revenue.

04 — The upstream rule it wrote

Pre-Submission Check: Validates multi-level hardware and add-on code linkage against payer-specific prior-authorization rules prior to clearinghouse transmission.

Cardiology

01 — The scenario

Emergent multi-vessel interventional cath lab procedure ($18,200 claim) denied for "Lack of Prior Authorization."

02 — The documentation gap

A diagnostic procedure escalated to an urgent therapeutic intervention mid-session, creating a coding mismatch between the original pre-authorization and final billed services.

03 — What PrismIQ did

Extracted real-time hemodynamics and cath lab clinical notes from the EHR, generating an immediate retroactive authorization package citing the payer's urgent intervention policy clauses.

04 — The upstream rule it wrote

Pre-Submission Check: Detects mid-procedure code escalations and routes claims for instant retroactive documentation assembly prior to batch billing.

Powering 2–25 provider specialty practices across California and nationwide

See a real authorization packet PrismIQ filed for a case like yours.

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