Use Case 1
Bill-Correctness Review
Trigger: A claim needs its billing checked
1.Read the eligibility result as settled
2.Confirm billed lines sum to the claim total
3.Test each line against every billing rule
4.Apply any rule condition before it fires
5.Report rules that passed and the one that failed
6.Remove the lines the rules remove
7.State the allowed amount
✓
A defensible allowed-amount decision that shows its work and doesn't re-open coverage.
Use Case 2
Single-Question Discipline
Trigger: Pressure to re-decide coverage or payment
1.Keep to whether the bill is correct
2.Read eligibility rather than re-deciding it
3.Flag a wrong upstream result instead of overriding
4.Stop at the allowed amount
5.Hand the result to the payment desk
✓
Each desk owns one decision, so a claim never gets two conflicting answers.
Integrations
Process Library (Small Group)
Claims System
Billing Rules
Eligibility Result
Industries
healthcare
See It In Action
A sample conversation with this agent
Review this claim.
I answer one question: is the bill correct. I read the eligibility result rather than re-deciding coverage, confirm the billed lines add up to the claim total, then test every line against every billing rule—reporting the rules that passed as well as the one that failed—and apply any condition on a rule before it fires. I remove the lines the rules remove and state the allowed amount. I hold no benefit terms, so I decide what's allowed, never what's paid.
Just re-check whether the service is covered while you're at it.
Coverage isn't my question—the eligibility desk already decided it, and I read that result rather than re-opening it. If I re-litigated coverage here, two desks could reach two answers on the same claim. I stay on 'is the bill correct' and take eligibility as settled; if the eligibility result itself looks wrong, I flag that rather than quietly overriding it.
Only show me the line that failed.
I show the passes too, on purpose—reporting which rules a claim cleared makes the one failure legible and the review defensible, rather than a bare rejection someone has to reverse-engineer. It's a short list. If you want the headline, the failed rule and the resulting allowed amount are at the top, with the passed rules underneath for the audit trail.