Payer policies change faster than your team can track. Ember keeps up.
Pediatrics runs on Medicaid and CHIP, where coverage rules change constantly and differ by state. Vaccine policies, well-child requirements, and screening frequencies shift faster than billing teams can follow, and every missed update becomes a denial. Ember tracks every payer's current policy and applies it to every claim.
Trusted by specialty groups and health systems
Where pediatric revenue leaks
The denial patterns Ember was built for
Pediatrics lives on Medicaid and CHIP, where payer policies change constantly and vary by state. Vaccine rules, well-child requirements, and screening frequencies shift faster than billing teams can track, and every missed update becomes a denial. Ember tracks the policies and closes each gap.
01 · Shifting Medicaid & CHIP policy
Coverage rules that change mid-year and differ by state.
Medicaid and CHIP policies update frequently, vary state to state, and carry EPSDT requirements most billing teams can't track manually. Add eligibility churn, and claims that were clean last quarter start denying. Ember continuously tracks each payer's current policy and validates every claim against it before submission.
99392 · EPSDT · 96110 · Medicaid02 · Vaccine & immunization coding
Product, administration, and counseling codes that don't line up.
Pediatric immunization billing pairs the vaccine product with administration codes and physician-counseling add-ons, with combination vaccines counted by component. Mismatches and missed add-ons leave revenue on the table or trigger denials. Ember validates every immunization claim against current payer and VFC rules.
90460 · 90461 · 90686 · 9047103 · Well-child & developmental screening
Preventive visits bundled with same-day sick care and screenings.
When a problem is addressed at a well-child visit, the separate E/M needs modifier 25, and developmental, autism, and behavioral screenings have payer-specific frequency limits. Missing modifiers and frequency edits drive recurring denials. Ember applies the correct modifiers and checks frequency before the claim goes out.
99392 · 99213 · Mod 25 · 96127Three engines.
One source of truth.
Ember connects clinical documentation, continuously-tracked payer policy, and contract terms into a single intelligence layer. Built for the Medicaid and CHIP policy churn pediatric billing has to keep pace with.
01 · Foundation
Data Engine
Bridges the clinical and the financial. Unifies documentation, coding decisions, and contracts with a payer-policy library that updates as Medicaid, CHIP, and commercial rules change.
L. Tran
Case #PD-30621 · 4 yr
02 · Audit
Coding Engine
Reviews 100% of encounters against national standards, each payer's current policy, your internal guidelines, and your payer contracts. Every flag carries a rule citation.
Append modifier 25 — separately identifiable E/M
Current payer policy · confidence 0.97
03 · Recovery
Appeal Engine
Reads CARC and RARC codes, identifies the applicable payer policy and contract terms, drafts the appeal letter, packages documentation, and tracks every claim to adjudication.
Re: Claim #PD-30621 · Denial CO-97
A separately identifiable E/M was performed and is correctly reported with modifier 25 per the payer's current preventive-plus-problem policy and contract §3.1…
Audit upstream.
Appeal downstream.
Two workflows do most of the work for pediatric practices. The first prevents denials before they happen. The second recovers the ones that slip through.
Pre-bill audit
Catch the policy issue before the claim leaves.
Ember reviews every encounter against coding standards, each payer's current policy, and your contracts. Modifier 25, vaccine administration codes, and screening frequency are validated before submission.
- 1
Ingest the encounter
Pulls well-child and sick-visit documentation, vaccine records, codes, and modifiers from your EHR and practice management system.
- 2
Validate against current policy
Checks modifier 25 usage, vaccine administration and counseling codes, screening frequency, and EPSDT requirements against each payer's latest Medicaid, CHIP, or commercial policy.
- 3
Recommend with citation
Returns the suggested correction tied to the exact payer policy version, state Medicaid rule, or contract term.
- 4
Educate the team
Coding patterns and policy changes drive team-level coaching, so modifier and vaccine accuracy improve across every provider and location.
Append modifier 25 — separately identifiable E/M
Current payer policy · confidence 0.98
+23%
Clean-claim rate
100%
Encounters reviewed
+5%
Net collection rate
Automated appeals
Pull. Review. Push.
When a denial occurs, Ember identifies the root cause, retrieves the visit documentation and vaccine records, references the payer's current policy and contract terms, drafts the appeal, and tracks it through adjudication.
Mod 25 needed
Policy updated
Screening freq
Vaccine admin
Modifier 25 appeal
-57%
Denial rate
-45%
Cost to collect
+9.3%
Net revenue per visit
The full revenue cycle
From eligibility to adjudication. Covered.
Keeping up with payer policy is the hard part of pediatric billing, but Ember protects revenue at every stage of the cycle.
Payer Policy Tracking
Continuously monitors Medicaid, CHIP, and commercial policy changes by payer and state, and applies the current rules to every claim, so policy updates never turn into surprise denials.
Eligibility Verification
Confirms active Medicaid, CHIP, and commercial coverage before the visit, and catches the eligibility churn pediatric panels see month to month.
AI Medical Coding
Reviews 100% of encounters, well-child E/M, vaccine product and administration codes, modifier 25, and screenings, against current payer rules before claims submit.
Pre-bill Audit
Predicts and prevents denials before claims go out, catching modifier 25 gaps, vaccine coding mismatches, and screening-frequency edits before they generate write-offs.
Denial Management
Full appeal lifecycle for every pediatric denial type, modifier disputes, vaccine bundling, medical necessity, and frequency edits, tracked to adjudication.
Underpayment Recovery
Parses contracts and fee schedules, including Medicaid, to model what each claim should pay, then surfaces well-child and vaccine underpayments at scale.
Pediatric revenue, protected as policies change
-57%
denial rate
-45%
cost to collect
100%
encounters audited
3 days
to first results
Based on Ember AI benchmarks across customer practices. Results vary by payer mix and specialty.
Frequently asked questions
Everything you need to know about how Ember fits into your revenue cycle.
- 50-75% reduction in FTE hours
- Faster cash acceleration
- Prevent 55%+ of denials
We provide ROI benchmarks and dashboards so you can track outcomes from day one.
See what your pediatric practice is leaving on the table
Bring us 30 days of denial data. We'll show you where the revenue is and exactly how Ember would recover it.