Use Case 1
Rule Change Test & Deploy
Trigger: Configuration change proposed for adjudication rule
1.Generate test claim batch covering scenarios affected by rule
2.Run batch through proposed rule against current rule (parallel)
3.Compare outputs; flag unexpected variances
4.Investigate variances and refine rule
5.Repeat until test batch passes target threshold
6.Route to claims operations for approval gate (HITL)
7.Deploy approved rule with rollback prepared
✓
Rule changes validated against real claims patterns before they touch production.
Use Case 2
Denial Pattern Optimization
Trigger: Quarterly denial review or anomaly alert
1.Cluster denials by reason code, payer, service category
2.Quantify dollar and volume impact of top patterns
3.Identify root cause per pattern (rule defect, MHPAEA violation, configuration gap)
4.Distinguish patterns to fix vs. patterns where the denial is correct
5.Draft rule changes per pattern
6.Route packaged recommendations for benefits and compliance review
✓
Denial patterns get diagnosed and remediated systematically rather than one ticket at a time.
Integrations
CAPS Platforms (Facets, QNXT, HealthRules)
EDI 837 / 835 Processing
Medicare Code Sets (CPT, HCPCS, REV)
Test Claim Batch Generator
Denial Analytics Warehouse
Approval Workflow (RequestApproval)
Industries
healthcare
See It In Action
A sample conversation with this agent
Run a test batch against the new telehealth parity rules before we deploy.
Loading 2,000-claim test batch covering all BH telehealth scenarios: 90834 with modifier 95 + POS 02, 90834 with modifier 93 + POS 02 (audio-only), POS 11 in-person controls, and edge cases for state-specific telehealth parity overlays (CA, NY, IL). Running. Results: 1,847 adjudicated as expected, 89 unexpected denials clustered around modifier-93 claims paying at 100% instead of the 80% rule, 64 OON telehealth claims that should have been excluded but paid. I'm flagging both as rule defects and drafting fixes. Will not deploy until test batch passes 99%+.
Why are we seeing a spike in CO-50 denials on PHP claims?
Pattern analysis on the last 30 days of denials. 412 PHP denials with reason CO-50 (medical necessity not established), concentrated on REV 0912/0913 from three carved-out vendor populations. Root cause: our edit rule requires a PA number, but the carve-out vendor is the adjudication owner and they don't always send PA numbers back in the 837. The fix isn't tightening medical necessity—it's loosening the PA-required edit when adjudication_owner=vendor. Drafting the rule change. Won't deploy without RequestApproval from claims ops; this is a HITL gate by design.
Generate the optimization report for this quarter's denials.
Quarter denial volume 18,420. Top 5 patterns by frequency and dollar impact: (1) CO-50 PHP carve-out misrouting—412 denials, $84K, fix above. (2) CO-197 missing auth on outpatient psych testing—298 denials, but 187 of those are MHPAEA-violating PA-on-BH-only patterns we should remove, not enforce. (3) Telehealth modifier mispricing—the rule fix above. (4) New CMS code G0560 not loaded in 11 plans—configuration gap. (5) Out-of-network BH claims paying full benefit when they shouldn't—$340K leakage. Optimization recommendations packaged for benefits configuration analyst review.