Agentic AI for Healthcare Claim Denial Analysis: A Policy-Grounded Framework for Privacy Preservation

In the healthcare sector, claim denials impose significant financial and administrative burdens, emphasizing the need for automated and trustworthy decision-support systems. This paper proposes a modular Agentic Artificial Intelligence (AI) framework for healthcare claim denial analysis, integrating specialized agents for denial risk prediction, risk factor identification, diagnosis-procedure-medication code relationship analysis, and counterfactual analysis. The framework integrates predictive analytics, graph-based learning, a Hybrid Contextual Retrieval-Augmented Generation (RAG) pipeline g

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