Governance & Program Info
Revenue Cycle AI & Denial Prevention — Governance
Cross-builder institution context and per-item ownership, due dates, status, and next actions for the governance-relevant checklist items in this builder.
Institution context
Program info
Applies across every builder in the app. Stored locally; nothing leaves the browser.
Checklist governance
Items (0 of 15 marked complete)
Annotate ownership, due date, status, and next action. Items on the left come from the builder's governance / compliance phases.
05 · Governance & Compliance
Complete HIPAA Security Rule risk assessment for the ML stack
Administrative, physical, and technical safeguards (45 CFR 164.308 / 164.310 / 164.312) mapped specifically to the training pipeline, feature store, inference runtime, and audit log.
05 · Governance & Compliance
Confirm Business Associate Agreements for every cloud component
Training infrastructure, feature store, inference runtime, monitoring tools, LLM API providers — all require executed BAAs if they process PHI.
05 · Governance & Compliance
Implement de-identification or Limited Data Set controls for training
Where training uses Safe Harbor de-identification (45 CFR 164.514) or Limited Data Set under DUA, controls must be documented and technically enforced.
05 · Governance & Compliance
Minimum necessary / access control for model outputs
Denial scores and appeal drafts contain PHI — role-based access, audit logging, and minimum-necessary enforcement per 164.514(d).
05 · Governance & Compliance
Map CMS-0057-F denial transparency obligations
Confirm which of the Final Rule's API, denial-reason structure, and reporting requirements apply to your payer partners and what you must ingest.
05 · Governance & Compliance
FHIR R4 integration attestation
Confirm HL7 FHIR R4 conformance for prior auth, patient access, and payer-to-payer data exchange touchpoints used as model inputs.
05 · Governance & Compliance
No Surprises Act balance-billing exposure review
Emergency and certain out-of-network claims carry NSA exposure — denial predictions on these claims must route to NSA-aware remediation, not standard appeal flow.
05 · Governance & Compliance
Adopt NIST AI RMF 1.0 control mapping
NIST AI RMF 1.0 (January 2023) provides the Govern / Map / Measure / Manage function set widely expected of healthcare AI systems even outside finance.
05 · Governance & Compliance
Document model purpose, scope, assumptions, and known failure modes
Model documentation artifact: intended use, training data window, assumptions, limitations, known failure modes, validation results.
05 · Governance & Compliance
Independent model validation
A team independent of development validates model logic, data, assumptions, and performance claims. Required by NIST AI RMF Measure function.
05 · Governance & Compliance
Explainability / SHAP reason-code output per decision
Per-claim feature attribution so coders, appeal teams, and auditors can understand why a claim was flagged. Required for coder trust and appeal defense.
05 · Governance & Compliance
LLM hallucination / grounding controls for appeal and remediation output
Appeal drafts must be grounded in cited policy (LCD / NCD / payer bulletin) and chart documentation — ungrounded LLM output is a compliance risk.
05 · Governance & Compliance
Change management and model versioning
Who approves model updates, what testing is required, how changes are versioned and rolled back, what the audit trail looks like.
05 · Governance & Compliance
Fair-use / disparate impact assessment
Denial prediction can inadvertently deprioritize patients from underserved areas if payer-mix proxies leak in — monitor for disparate impact on protected classes.
05 · Governance & Compliance
Incident response and breach notification readiness
HIPAA Breach Notification Rule (45 CFR 164.400–414) requires 60-day notification post-discovery. Plan for model compromise, training-data exfiltration, and LLM prompt-injection scenarios.