PacketProof Health
See the gaps before the denial.
Medical-necessity packets and peer-to-peer briefs for high-friction MSK prior auth — built from the chart against payer criteria, so specialty ortho teams catch what’s missing before submit.
A Gap Card and P2P battle card before you submit — so the packet shows what’s missing against payer criteria.
Try the demo with sample charts — do not upload real patient records.
Problem
High-friction MSK prior auth fails when the packet is missing what major payers and benefit managers (e.g. eviCore or Carelon) actually require. Specialty ortho teams assemble a chart, submit, and learn after the fact that imaging, conservative care, or a contraindication note was not in the file. The denial is often a documentation gap — not a clinical disagreement.
What it does
A coordinator drops a chart PDF, picks a CPT and a reviewer, and gets two clinic-facing outputs before submit.
High-friction MSK / ortho — starting with eviCore + Carelon and a defined CPT set.
01
Upload the chart
Upload the chart the team already has — notes, imaging, conservative-care history.
02
Select CPT and reviewer
Pick the procedure code and the reviewer that will actually see the packet.
03
Get Gap Card + P2P battle card
A Pre-Flight Gap Card (what is missing before submit) and a peer-to-peer battle card (talking points if the case goes to P2P).
Today: chart PDF in. EHR write-back / portal submit: out of scope for this product.
How it works
The LLM extracts. The rules decide. The model does not approve, deny, or invent criteria.
- 1
Map payer policies
Pull eviCore / Carelon MSK criteria for a CPT. The rules decide what the packet must show — the model does not invent criteria.
- 2
Digitize requirements
Encode that policy as a deterministic rule graph. The rules decide; the model does not invent criteria.
- 3
Analyze the chart
The LLM extracts facts from the chart against the graph. The rules decide. The model does not invent criteria.
- 4
Identify missing data
Deterministic rules compare extracted facts to the graph. The rules decide — no model adjudication. The model does not approve, deny, or invent criteria.
- 5Pilot / roadmap
Appeal / P2P draft support
Letter-draft support from the Gap Card, graph cites, and extracted facts. The LLM extracts; the rules decide — the model does not invent criteria. Pilot / roadmap — not a shipped Appeal Drafter, and not a full post-service claim-appeal workflow.
Who
Independent orthopedic groups and specialty MSK teams working high-friction prior auth across major payers and benefit managers (e.g. eviCore or Carelon). Not a payer portal, not a BPO click-shop, and not a hospital RCM suite.
Pilot
Design-partner pilots run on synthetic or redacted charts until business associate agreements (BAAs) are in place. This public site does not accept charts, store PHI, or connect to Blob. No real patient records until BAAs exist with every vendor that would see them.