CodeGuard is Orchid’s pre-bill claim validation engine for hospitals. It increases first-pass accuracy and reduces preventable rework by checking the billed story (diagnoses, procedures, DRG drivers, POA, and key claim elements) against chart evidence and applicable payer requirements. It returns fix-ready findings with citations, a traceable rationale, and an audit trail.

Preventable means the evidence is present (or obtainable via a realistic pre-bill workflow) and the fix is actionable before submission.

Pre-bill, before final claim submission, aligned to your DNFB and coding/CDI review cadence.

Not a clearinghouse, not a billing system, not an auto-coder that submits claims.

CodeGuard reviews the encounter’s coded story and supporting documentation, pulls relevant policy or guidance excerpts with citations, and explains the decision path in plain language for coders, CDI, HIM, and RCM leadership.

Each flag includes:

• The policy or guidance excerpt with citation.
• The decision path and claim fields involved.
• A linkable evidence packet with chart excerpts and traceability to claim and remit fields.

This supports internal review and denial response workflows. It does not replace payer-specific appeal templates, internal policy, or legal review.

We support Limited Data Set (LDS) workflows under minimum-necessary design and the appropriate agreements (BAA and, when required for LDS disclosure, a DUA), aligned to your legal and privacy requirements.

No. The goal is accurate, compliant billing. We flag both over-coding and under-coding and record user actions so your team stays in control.

Not to run Phase 0. Phase 0 impact is grounded in your remit history. Contract terms can improve pricing precision and payer-specific rule mapping, and we can layer them in when your team is comfortable.

We price from remits, separate verified vs preventable, and publish confidence bands.

Phase 0 is a short, offline retrospective study that answers one question: should we run a live pilot together, or walk away.

We use a limited, agreed-upon historical claim set to:

• Verify financial leakage using your remit history, not charges.
• Identify the subset that is credibly preventable with pre-bill intervention.
• Produce an executive summary with clear buckets and root causes.
• Provide a small set of audit-grade evidence packets your HIM and RCM leaders can validate quickly.

Phase 0 ends with a go or no-go recommendation, backed by measurable results and transparent assumptions.

• 837I or UB-04 (institutional claim file) and 835 (remittance file showing allowed, paid, and adjustment reasons).
• Encounter identifiers and payer product identifiers. Hospital-generated encounter tokens are acceptable.
• A scoped evidence bundle from the chart.

We quantify impact from remits, then explain root causes using claim fields plus chart evidence. We provide a data dictionary request to make this easy.
 

Executive summary, leakage taxonomy, validated case packets, dollars with confidence bands (grounded in 835), and a pilot readiness recommendation.

Phase 0 is designed to be low-burden. Most of the effort is upfront data extraction and a short validation review.

Typical involvement:

• Technical contact (billing/analytics/IT): provides the agreed extracts (837I or UB-04, 835, and the scoped chart evidence bundle). Usually 2 to 6 hours total once the mapping is clear (varies by system and approvals).
• HIM/Coding lead: reviews a small, representative sample of flagged cases to confirm correctness and calibrate categories. Usually 1 to 2 hours per week during the study.
• RCM leader: reviews the executive summary, impact rollup, and go or no-go recommendation. Usually 60 to 90 minutes total.

We provide a simple data dictionary, a lightweight kickoff, and a structured validation workflow so your team can confirm results without disrupting day-to-day operations.

Three easy steps:

1. Scoping call (confirm scope, payers, time period, success criteria).
2. Data request (we provide the dictionary and templates).
3. Kickoff (agree validation sample and reporting cadence).
    

If Phase 0 shows meaningful, verifiable impact and workflow fit, we move to a 6-month Pilot (Phase 1) for the same encounter types and payers.

Phase 1 is 6 months and includes:

• Secure onboarding and mapping for the agreed scope.
• Ongoing batch processing aligned to your pre-bill cadence.
• Role-aligned outputs for HIM, CDI, coding, and RCM.
• A structured validation workflow (sampling, disagreements, resolution).
• Monthly reporting that separates verified results from directional risk exposure.
• Operational support and a joint cadence for tuning and workflow fit.

Fewer preventable denials, less rework, and faster correction cycles, proven on your encounters and payers, with clear exit criteria agreed up front.

We jointly choose one of three paths:

1. Move to production for the same scope.
2. Expand scope (additional payers, DRG families, or clinical domains).
3. Stop, if impact or workflow fit is not sufficient.