RISK AND REVENUE INTELLIGENCE
When regulatory change hits your bottom line.
Six-month Medi-Cal redeterminations start December 31, 2026.
Roughly two million California members are at risk of losing coverage — most of them for paperwork reasons, not eligibility reasons. Every one of those is a patient who stops showing up and a claim that never gets paid.
We codify redetermination and CalAIM billing requirements into a deterministic rules engine that checks every patient record before a renewal date passes or a claim goes out. Your team gets a prioritized list of what needs attention, and why, in plain language.
The deadline is fixed. The paperwork is not.
Dec 31, 2026
SIX-MONTH REDETERMINATIONS BEGIN — NO OPTION TO DELAY
~2M
MEDI-CAL MEMBERS AT RISK OF LOSING COVERAGE
74%
OF PRIOR DISENROLLMENTS WERE PROCEDURAL, NOT ELIGIBILITY
2X
THE ADMINISTRATIVE SURFACE AREA, STARTING IMMEDIATELY
Under H.R. 1, Medicaid expansion adults move from annual to six-month eligibility renewals effective December 31, 2026. California DHCS published its implementation plan in January 2026. There is no state option to delay this provision.
For behavioral health providers and FQHCs, this doubles the number of times each year that a patient can fall out of coverage because a form did not get returned — and the population least equipped to manage paperwork is the population you serve.
Sources: H.R. 1 §71107; CMS SMD #26-001; California DHCS H.R. 1 Implementation Plan (January 30, 2026)
Three places revenue leaks — and none of them are clinical.
The renewal nobody tracked
A patient's redetermination date passes. Nobody flagged it. Nobody knew their address on file was stale. Coverage lapses mid-treatment, the patient stops coming, and the sessions you already delivered become unbillable.
The claim that was almost right
The ECM documentation was thorough. The care coordination happened. But the modifier didn't match the managed care plan's requirement, and the claim came back denied — weeks later, when reworking it costs more than it recovers.
The audit you can't answer
DHCS asks how a service met medical necessity. The documentation exists, somewhere, across three systems and a shared drive. Assembling the answer takes a week of staff time you didn't budget.
A rules engine for the requirements. A copilot for your team.
Redetermination risk monitoring
Every patient scored against their renewal date, contact information currency, and documentation completeness. Your care coordination team gets a weekly prioritized outreach list — who needs attention, what's missing, and how many days remain.
Plain-language guidance
When something fails a check, your billing specialist sees what failed, why it matters, and the specific steps to fix it — with a citation to the exact DHCS or plan requirement behind it. No decoder ring required.
Pre-submission claim evaluation
Every claim checked against the specific documentation, coding, and modifier requirements for that service, that payer, and that program — before it is submitted, not after it is denied.
An audit trail that already exists
Every evaluation is timestamped and immutable. When DHCS or a managed care plan asks how a determination was made, the answer is already assembled — data, rule, reasoning step, outcome.
We take the documentation and eligibility requirements your organization actually operates under — H.R. 1 redetermination rules, CalAIM ECM and Community Supports billing standards, your managed care plan's specific modifier requirements — and codify them into deterministic rules that evaluate every record before it matters.
Built for the organizations carrying the most exposure.
Behavioral health providers
SUD treatment programs, outpatient mental health practices, and community behavioral health agencies where Medi-Cal is the majority of revenue. Your patients are disproportionately affected by redetermination churn, and CalAIM documentation requirements are the most complex in the state.
Federally Qualified Health Centers
FQHCs managing renewal navigation across large patient panels with community health worker teams doing it patient by patient. We turn that into a systematic, prioritized weekly workflow.
County and managed care behavioral health plans
Organizations responsible for network-wide compliance performance, where a provider's documentation gap becomes your DHCS contract problem.
We have already built this architecture in a regulated environment.
For Luveo Health, an enterprise pharmacy operations platform, we codified 28 compliance rules across 7 operational workflows — covering DEA, DSCSA, HIPAA, USP 797, and state Board of Pharmacy requirements — then layered a governed AI copilot that translated every rule outcome into cited, plain-language guidance for pharmacy technicians.
Across a 30-scenario structured evaluation, the copilot scored 97% on explanation accuracy and 100% on chat accuracy, with zero hallucinated rule keys, zero fabricated regulatory citations, and zero guardrail violations. The rules engine was load-tested at 35 events per second.
Different regulations. Same architecture. Delivered in two 4-week cycles.
Reasonable questions.
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Your billing company submits claims. This evaluates whether a claim will survive submission before it goes out, and whether a patient's record supports continued eligibility before their renewal date. Most billing partners welcome it — fewer denials to rework is good for both of you.
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Documentation quality and documentation compliance are different problems. A thorough note can still fail a plan-specific modifier requirement. The question is not whether your clinicians document well — it is whether anything systematically checks that documentation against the requirement that applies to that specific claim, payer, and program.
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Yes, and it is built for that. We execute a BAA before any data access, work in isolated environments, and tokenize PHI at the ingestion boundary so protected data never reaches the AI layer directly.
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That is exactly why the cycle is four weeks. A cycle started this quarter is in production well before the first six-month renewal wave. A cycle started in November is not.
Find out in 30 minutes whether this fits.
We will ask you three questions: which workflow is leaking, what data sits behind it, and what "fixed" looks like to you. If we can scope it into a four-week cycle, we will tell you exactly what that includes and what it costs. If we cannot, we will tell you that too.