GAVEL

Payers run an industrial stack built to pay less: prior-authorization algorithms, prepay edits, automatic downcoding, DRG downgrades, repricers, post-pay clawbacks. It works because they know the rules and providers meet them one denial at a time.

The rules just became readable. Interoperability and prior-authorization rules and the transparency files put the payer’s own text on the public record. The side that encodes it first sets the terms.

Will it be covered?

Plan benefits, medical policies, posted criteria, LCD and NCD, prior-authorization lists. Cited.

What will it take?

The exact criteria, documentation and codes that clear the gate, mapped to the payer’s own text.

What will they pay?

Contract terms, fee schedules, transparency benchmarks, repricer patterns.

What did they just do?

Remit decode: denial, downcode, underpay, clawback. Appealable? Inside what window? The packet, built.

Every answer carries citations into source text and a proof record built to survive a payer audit, a regulator or a courtroom. GAVEL flags the weak claim as readily as the underpaid one. That is what makes it usable by a compliance officer and not only by a billing team.

Digital health or device company

Market access in software: code strategy with precedent, a plan-by-plan policy map, payer dossiers for sales, policy-change alerts.

Specialty group or MSO

The defense stack: pre-bill validation, downcode and underpay detection, automated appeals.

RCM platform or health-tech AI

An embedded API: the payer rulebook and behavior your product needs, without building it.

1. THE PILOT

   Twelve months of remits and your top three payers. Thirty days later you have your money map: where you were underpaid, downcoded or wrongly denied, and which of it is still appealable.

• It does not predict an adjudication. It tells you what the payer’s published text requires and what the remit shows they did.
• It does not upcode. A claim the record does not support is flagged, not strengthened.