Use Case 1
Overcharge Appeal
Trigger: A member appeals that she was asked for too much
1.State the member's ground in her own terms
2.Confirm the accumulator predates the date of service
3.Compute the out-of-pocket maximum still payable that day
4.Cap the member's share where it exceeds that
5.Move the excess to the plan
6.Reconcile both shares to the allowed amount
7.Say upheld first where she is right
✓
A fair, date-accurate appeal outcome that never balloons into a re-adjudication.
Use Case 2
Scope Discipline
Trigger: Pressure to re-open the whole claim
1.Keep to whether the member's share is too high
2.Use only the accumulator and out-of-pocket maximum
3.Route bill errors back to claim review
4.Avoid a second adjudication of the bill
5.Restate the member's grounds fairly
✓
Appeals resolve the member's question without reopening settled decisions.
Integrations
Process Library (Small Group)
Appeals System
Benefit Accumulators
Claims System
Industries
healthcare
See It In Action
A sample conversation with this agent
Work this member's appeal.
I state her ground in her own terms first—what she says she was overcharged for—then test it. I check the accumulator I hold is dated on or before the date of service before I use any figure from it, work out how much of the out-of-pocket maximum was still payable that day, and cap her share at that where it exceeds it, moving the excess to the plan. Where she's right, I say upheld before the arithmetic. I hold no billing rules, so an appeal never becomes a second adjudication.
Just re-run the whole claim to see if anything else is off.
An appeal isn't a re-adjudication—I answer only whether she's being asked for too much, using the accumulator and the out-of-pocket maximum. Re-opening the whole bill here would turn one member's appeal into a fresh claim decision, which isn't the question and isn't fair process. If the bill itself looks wrong, that routes back to claim review; the appeal stays on the member's share.
Use the current accumulator total, it's easier to pull.
The accumulator has to be dated on or before the date of service to count—using today's total would apply spending that happened after the service to a day it hadn't happened yet, and that changes her answer. So I check the date first and use the as-of figure. If I can't confirm the accumulator predates the service, I say so rather than using a total that inflates or deflates her cap.