BYOR Governance — Local Rule Overlays

Denial learnings encoded as deterministic governance. No code changes.

Without governance overlays, preventable denials pass through. Apply local rules — NCCI edits, modifier requirements, linkage checks, and payer-specific denial patterns — before submission.

6Rules active

LocalExecution

VersionedAudit trail

WeeklyRule evolution

Claim draft — no governance overlays

Patient Context

71yo male · Medicare Advantage · CHF, DM, CKD, COPD, AFib

DOS: 2026-02-11 · Provider: [Synthetic]

Diagnoses

I50.23Acute on chronic systolic heart failure

HCC 224

I50.22Chronic systolic heart failure

HCC 226

E11.22Type 2 DM with diabetic CKD

HCC 18

N18.32CKD stage 3b

HCC 329

J44.9COPD unspecified

HCC 280

I48.21Permanent atrial fibrillation

HCC 223

Procedures

99214Office visit, established patient, moderate complexity

93000Electrocardiogram, routine ECG

Modifiers Present

None — no modifiers appended

Authorization

Medicare Advantage — no prior auth required for E/M

No Governance Overlays — Preventable Denials Pass Through

This claim draft was built by deterministic extraction — diagnoses are correct, evidence-tethered, and HCC-mapped. But without governance overlays, billing-level errors pass through unchecked.

✖NCCI edit conflict: 99214 + 93000 bundled without modifier — auto-denial on submission

✖Modifier 25 missing on E/M — ECG payment denied

✖E11.22 submitted without diabetic eye exam linkage — payer may downgrade to E11.9

✖I48.21 submitted to UHC MA without rhythm documentation — downgrade to I48.91

Extraction stabilizes clinical truth. Governance prevents billing-level denials. These are not extraction failures — they are rule enforcement gaps that local governance overlays close.

Rules run locally. No PHI egress required.