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Trajectory · Claim #383348 · trial 1

GPT-5.5 openai

Full agent trajectory — every tool call, replayable step by step.

Reward

0.80

Coding

100%

Tool calls

Final stage

closed_paid

Tool-by-tool trajectory · 27 tool calls

#0 portal_login I need payer portal access before verifying active coverage and later retrieving remittance information, so I’m... ＋

Agent reasoning

I need payer portal access before verifying active coverage and later retrieving remittance information, so I’m starting the portal login workflow and expect an OTP prompt/result next.

Args · stage intake · day 0

{}

Result

{"ok": true, "note": "OTP sent to registered device; call portal_verify_otp with code 000000 (sim)"}

#1 portal_verify_otp I need to complete payer-portal access before I can verify eligibility and later retrieve any payer responses/ERA.... ＋

Agent reasoning

I need to complete payer-portal access before I can verify eligibility and later retrieve any payer responses/ERA. The OTP was issued, so I will verify it now to establish the portal session.

Args · stage intake · day 0

{"code": "000000"}

Result

{"ok": true, "note": "authenticated to payer portal"}

#2 check_eligibility Before coding or billing, I need to verify active coverage for the date of service and identify any... ＋

Agent reasoning

Before coding or billing, I need to verify active coverage for the date of service and identify any COB/primary-payer issues from the 271 response. This will confirm whether BCBS Empire PPO is billable as primary or if another payer must be coordinated first.

Args · stage eligibility · day 0

{}

Result

{"ok": true, "coverages": [{"rank": "primary", "payer": "BCBS OF NY EMPIRE PPO FS", "member_id": "MCCE92AA31", "group": "GRP-BAEE", "status": "active", "copay_cents": 2500, "deductible_remaining_cents": 0}], "cob_required": false, "note": "active coverage verified"}

#3 review_documentation I need to complete the coder documentation review before assigning diagnoses and CPT codes, and determine whether... ＋

Agent reasoning

I need to complete the coder documentation review before assigning diagnoses and CPT codes, and determine whether any ambiguity requires a provider query. This should identify documentation gaps such as whether the SNOMED diagnosis is supported and whether any billable orders/procedures were performed.

Args · stage documentation · day 0

{}

Result

{"ok": true, "doc_state": "coder-reviewed", "provider_query_needed": false, "findings": []}

#4 read_chart Before deriving ICD-10/CPT and submitting, I need to verify the encounter documentation directly in the chart tool,... ＋

Agent reasoning

Before deriving ICD-10/CPT and submitting, I need to verify the encounter documentation directly in the chart tool, including the sore throat findings, absence of orders, and any billable activities that may not appear in the summary.

Args · stage documentation · day 0

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 11:23:00  |  End Time: 11:38:00  |  Length of Stay: 15 min  |  Reason: Throat hurts bad hard time swollowing  |  Visit type: UC - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHPI: sore throat with difficulty swallowing, fever,. chills, , Onset:  gradual, Severity:  mild\n[ORAL CAVITY:] mucosa moist, palate normal\n[LUNGS:] clear to auscultation bilaterally, no wheezes, rales, rhonchi\ …[truncated]

#5 capture_charges Coverage and documentation review are complete, and there are currently no captured charges. I will run charge... ＋

Agent reasoning

Coverage and documentation review are complete, and there are currently no captured charges. I will run charge capture to aggregate any billable professional services from the encounter before assigning ICD-10/CPT lines.

Args · stage charge_capture · day 0

{}

Result

{"ok": true, "charge_feed": [{"source": "lab", "activity": "in_house_lab", "clia_waived": true, "description": "In-house lab performed: Infectious agent antigen detection, Streptococcus group A (rapid strep) (CLIA-waived rapid test)."}, {"source": "visit", "description": "ESTABLISHED patient office/urgent-care evaluation & management visit; 1 problem(s) addressed; total time: not documented. Read the progress note for history/exam/data ordered/risk and assign the E/M level (CPT) per the 2021 MDM …[truncated]

#6 kb_lookup_icd10 The primary SNOMED/problem and clinical note indicate streptococcal sore throat/pharyngitis, so I need to verify the... ＋

Agent reasoning

The primary SNOMED/problem and clinical note indicate streptococcal sore throat/pharyngitis, so I need to verify the ICD-10-CM code before setting Box 21. I expect J02.0 to be the correct specific diagnosis for documented streptococcal pharyngitis.

Args · stage charge_capture · day 0

{"code": "J02.0"}

Result

{"code": "J02.0", "found": true, "description": "Streptococcal pharyngitis", "note": "Description only - confirm this is the specific code the documentation supports before committing it."}

#7 kb_coding_guidelines I need to translate the captured urgent-care activities into the correct billable code family before setting service... ＋

Agent reasoning

I need to translate the captured urgent-care activities into the correct billable code family before setting service lines, especially because urgent-care global services may require an S-code instead of a standard E/M. I will check the service-line coding rules so I can select the correct CPT/HCPCS and avoid wasting a submission.

Args · stage charge_capture · day 0

{"topic": "service_lines"}

Result

{"topic": "service_lines", "guidelines": ["The charge feed describes clinical ACTIVITY, not codes. Derive every CPT/HCPCS yourself from the documented orders/procedures/meds/time.", "One service line per billable activity: E/M, each in-house lab, each imaging study, each procedure, each drug administered.", "Drug (HCPCS J/Q) lines must carry the 11-digit NDC + drug units (set_service_lines ndc/ndc_units/ndc_uom). Look up the NDC for a known drug code with kb_lookup_cpt code=\"J####\".", "Ordered …[truncated]

#8 kb_coding_guidelines The chart is an urgent-care new visit and the instructions warn that some urgent-care charge-feed activity may... ＋

Agent reasoning

The chart is an urgent-care new visit and the instructions warn that some urgent-care charge-feed activity may require a global UC HCPCS rather than a standard E/M. I need the payer/workflow rule for urgent-care service-line selection before committing CPT/HCPCS lines.

Args · stage charge_capture · day 0

{"topic": "urgent_care"}

Result

{"topic": "urgent_care", "guidelines": ["Map each charge-feed 'activity' to its code family - YOU then pick the exact code from the documentation:", "  activity=evaluation_and_management -> office/UC E/M, leveled by MDM/time (99202-99205 new, 99212-99215 established). See topic=\"em\".", "  activity=urgent_care_global -> the URGENT-CARE GLOBAL per-visit case-rate HCPCS S9083. Some payers contract urgent care as a single global fee rather than fee-for-service; when the feed shows a global facilit …[truncated]

#9 get_status I need to see the current charge-capture details and case state before selecting CPT/HCPCS lines, because the chart... ＋

Agent reasoning

I need to see the current charge-capture details and case state before selecting CPT/HCPCS lines, because the chart has no explicit order list but the charge feed captured 2 activities. This should clarify whether the captured activities are E/M/global urgent-care/lab before I commit service lines.

Args · stage charge_capture · day 0

{}

Result

{"stage": "charge_capture", "sim_day": 0, "logged_in": true, "coverage_confirmed": true, "eligibility": {"checked": true, "coverages": [{"rank": "primary", "payer": "BCBS OF NY EMPIRE PPO FS", "member_id": "MCCE92AA31", "group": "GRP-BAEE", "status": "active", "copay_cents": 2500, "deductible_remaining_cents": 0}], "cob_required": false, "cob_resolved": true, "wrong_payer_on_chart": false, "primary_payer": "BCBS OF NY EMPIRE PPO FS"}, "n_open_queries": 0, "n_charges_captured": 2, "authorization_ …[truncated]

#10 read_chart I need to confirm whether any ordered lab/specimen activity is documented outside the progress note before assigning... ＋

Agent reasoning

I need to confirm whether any ordered lab/specimen activity is documented outside the progress note before assigning CPT/HCPCS lines, especially because charge capture found two activities despite orders showing N/A in the summary. I am opening the orders section specifically to verify whether a lab, specimen collection, or ordering/referring NPI requirement applies.

Args · stage charge_capture · day 0

{"section": "orders_(from_progress-note_xml)"}

Result

{"section": "orders_(from_progress-note_xml)", "body": "(no such section)"}

#11 set_diagnoses The documented primary SNOMED diagnosis corresponds to streptococcal sore throat/pharyngitis, which was already... ＋

Agent reasoning

The documented primary SNOMED diagnosis corresponds to streptococcal sore throat/pharyngitis, which was already verified as ICD-10-CM J02.0. Fever, sore throat, and swallowing difficulty are symptoms of the definitive throat infection and should not be sequenced ahead of the confirmed diagnosis.

Args · stage coding · day 0

{"codes": ["J02.0"]}

Result

{"ok": true, "diagnoses": [{"sequence": 1, "code": "J02.0"}]}

#12 kb_lookup_cpt Before setting Box 24, I need to verify the urgent-care global HCPCS that may replace a separate E/M for this... ＋

Agent reasoning

Before setting Box 24, I need to verify the urgent-care global HCPCS that may replace a separate E/M for this payer/charge type, because the chart is an urgent-care new visit and the charge feed has captured clinical activity without codes.

Args · stage coding · day 0

{"code": "S9083"}

Result

{"code": "S9083", "found": true, "desc": "Global fee, urgent care centers (per-visit case rate)", "category": "global", "keywords": ["urgent care", "global", "case rate"]}

#13 kb_lookup_cpt The chart’s charge capture shows two charges but service lines are still unset; because this was an urgent-care... ＋

Agent reasoning

The chart’s charge capture shows two charges but service lines are still unset; because this was an urgent-care visit and the prior lookup confirmed S9083, I need to verify the likely second code for a documented throat/strep test before committing the claim lines.

Args · stage coding · day 0

{"code": "87880"}

Result

{"code": "87880", "found": true, "desc": "Infectious agent antigen detection, Streptococcus group A (rapid strep)", "category": "lab", "clia_waived": true, "keywords": ["strep", "streptococcus", "rapid strep", "group a"]}

#14 set_service_lines The encounter appears to have an urgent-care global visit plus a documented strep antigen test charge already... ＋

Agent reasoning

The encounter appears to have an urgent-care global visit plus a documented strep antigen test charge already captured, and there are no drugs/NDCs or prior-auth services. I’m setting Box 24 with the urgent-care global case-rate and the rapid strep test, pointing both to the confirmed strep pharyngitis diagnosis and using POS 11 from the chart.

Args · stage coding · day 0

{"lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11"}, {"cpt": "87880", "modifiers": ["QW"], "units": 1, "dx_pointers": [1], "place_of_service": "11"}]}

Result

{"ok": true, "service_lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11", "ndc": ""}, {"cpt": "87880", "modifiers": ["QW"], "units": 1, "dx_pointers": [1], "place_of_service": "11", "ndc": ""}]}

#15 set_claim_header The claim includes a diagnostic lab line (87880), and the chart identifies Dr. Patel as the ordering/rendering... ＋

Agent reasoning

The claim includes a diagnostic lab line (87880), and the chart identifies Dr. Patel as the ordering/rendering provider. I need to populate Box 17b with the ordering provider NPI before scrub to avoid a referring/ordering-provider edit.

Args · stage coding · day 0

{"referring_npi": "1700802145", "prior_auth_number": ""}

Result

{"ok": true, "updated": ["referring_npi", "prior_auth_number"], "claim_header": {"onset_date": "", "referring_npi": "1700802145", "referring_name": "", "prior_auth_number": "", "accident_type": "", "claim_notes": ""}}

#16 run_scrub The claim has eligibility, COB, provider identity, diagnosis, service lines, and header populated. I will run the... ＋

Agent reasoning

The claim has eligibility, COB, provider identity, diagnosis, service lines, and header populated. I will run the pre-submission scrub now to catch any payer/NCCI/modifier/referring/medical-necessity issues before using a submission attempt.

Args · stage coding · day 0

{}

Result

{"ok": true, "issues": [], "n_issues": 0, "note": "scrub clean"}

#17 submit_claim Eligibility, COB, provider identity, diagnoses, service lines, header, and scrub are already complete and clean. No... ＋

Agent reasoning

Eligibility, COB, provider identity, diagnoses, service lines, header, and scrub are already complete and clean. No prior authorization or NDC is required for these non-drug urgent-care/rapid-test lines, so the next step is to transmit the first 837P and review payer intake/remittance results.

Args · stage denial · day 16

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-3f5fe610ad", "status": "denied", "billed_cents": 15000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 15000, "claim_control_number": "CCN383348-1", "lines": [{"cpt": "S9083", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-16", "rarcs": ["M51"]}, {"cpt": "87880", "billed_cents": 5000, "paid_cents": 0, "carc": "CO-4", "rarcs": ["N519"]}], "carcs": ["CO-16", "CO-4"], "rarcs": ["M51", "N519"],  …[truncated]

#18 kb_lookup_carc The payer denied both lines for invalid/missing procedure coding, so I need the CARC guidance before changing the... ＋

Agent reasoning

The payer denied both lines for invalid/missing procedure coding, so I need the CARC guidance before changing the claim. I will look up CO-16 to confirm the required correction path for the unsupported S9083/global billing issue and related invalid procedure elements.

Args · stage denial · day 16

{"carc": "CO-16"}

Result

{"code": "CO-16", "found": true, "rarcs": [{"code": "MA130", "narrative": "Your claim contains incomplete and/or invalid information."}, {"code": "M51", "narrative": "Missing/incomplete/invalid procedure code(s)."}], "narrative": "Claim/service lacks information needed for adjudication.", "remedy": "Populate the missing field (member ID, NPI, dx pointers, etc.) and resubmit.", "appealable": "yes"}

#19 portal_download_era The claim denied at adjudication with CO-16/M51 on both lines, and before changing coding I need the full ERA/EOB... ＋

Agent reasoning

The claim denied at adjudication with CO-16/M51 on both lines, and before changing coding I need the full ERA/EOB detail to confirm the exact payer edits, line-level adjudication, and any additional remark codes not shown in the status summary.

Args · stage denial · day 16

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN383348-1\n  Status: DENIED\n  Billed:      $150.00\n  Allowed:     $0.00\n  Paid:        $0.00\n  Pt resp:     $0.00\n  Contractual: $150.00\n  CARC: CO-16, CO-4\n  RARC: M51, N519\n    S9083: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-16 M51]\n    87880: billed $50.00 paid $0.00 PR $0.00  [DENIED CO-4 N519]", "era": {"remit_id": "era-3f5fe610ad", "status": "denied", "billed_cents": 15000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cen …[truncated]

#20 kb_lookup_payer_policy The denial specifically says S9083 is unsupported/unbundled and 87880 has invalid modifiers for this payer, so I... ＋

Agent reasoning

The denial specifically says S9083 is unsupported/unbundled and 87880 has invalid modifiers for this payer, so I need the Empire PPO companion/payer policy before changing codes and risking another submission. I expect this to clarify whether urgent care should be billed with standard E/M instead of S9083 and whether modifier QW is accepted or suppressed for rapid strep testing.

Args · stage denial · day 16

{}

Result

{"payer": "BCBS OF NY EMPIRE PPO FS", "payer_class": "COMMERCIAL", "policy": {"timely_filing_days": 90, "appeal_window_days": 180, "common_denials": ["CO-167", "CO-A1", "CO-22"], "modifier_25_required_for_em_with_procedure": true}, "companion_guide": {"timely_filing_days": 240, "appeal_levels": ["first_level_appeal", "second_level_appeal", "external_review"], "denial_timing_days": 14, "auth_required_services": ["70551", "70553", "72148", "73721", "20610"], "payer_id": "36160"}}

#21 kb_coding_guidelines The denial specifically says the urgent-care global HCPCS and rapid-strep modifier are invalid and that documented... ＋

Agent reasoning

The denial specifically says the urgent-care global HCPCS and rapid-strep modifier are invalid and that documented services may be unbilled, so I need to re-derive the line coding rather than resubmit. I will first check the service-line coding rules for how this payer/workflow expects urgent-care global services versus fee-for-service E/M and ancillary tests before changing the claim.

Args · stage denial · day 16

{"topic": "service_lines"}

Result

{"topic": "service_lines", "guidelines": ["The charge feed describes clinical ACTIVITY, not codes. Derive every CPT/HCPCS yourself from the documented orders/procedures/meds/time.", "One service line per billable activity: E/M, each in-house lab, each imaging study, each procedure, each drug administered.", "Drug (HCPCS J/Q) lines must carry the 11-digit NDC + drug units (set_service_lines ndc/ndc_units/ndc_uom). Look up the NDC for a known drug code with kb_lookup_cpt code=\"J####\".", "Ordered …[truncated]

#22 read_chart The denial specifically says the procedure codes/modifiers do not match the documented service and that something... ＋

Agent reasoning

The denial specifically says the procedure codes/modifiers do not match the documented service and that something documented may be unbilled. I need to re-open the clinical note to distinguish the billable visit type/E/M from any documented throat testing or send-out specimen handling before changing the denied lines.

Args · stage denial · day 16

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 11:23:00  |  End Time: 11:38:00  |  Length of Stay: 15 min  |  Reason: Throat hurts bad hard time swollowing  |  Visit type: UC - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHPI: sore throat with difficulty swallowing, fever,. chills, , Onset:  gradual, Severity:  mild\n[ORAL CAVITY:] mucosa moist, palate normal\n[LUNGS:] clear to auscultation bilaterally, no wheezes, rales, rhonchi\ …[truncated]

#23 set_service_lines The denial specifically rejected the urgent-care global S9083 and the QW modifier on 87880, and indicates the... ＋

Agent reasoning

The denial specifically rejected the urgent-care global S9083 and the QW modifier on 87880, and indicates the documented visit service was effectively unbilled. I will replace S9083 with the supported new-patient office E/M level supported by low MDM for acute strep pharyngitis, and remove QW from the rapid strep line for this payer.

Args · stage coding · day 16

{"lines": [{"cpt": "99203", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11"}, {"cpt": "87880", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11"}]}

Result

{"ok": true, "service_lines": [{"cpt": "99203", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11", "ndc": ""}, {"cpt": "87880", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "11", "ndc": ""}]}

#24 run_scrub The corrected lines have been changed away from the denied S9083 configuration, but before using another submission... ＋

Agent reasoning

The corrected lines have been changed away from the denied S9083 configuration, but before using another submission I need the payer/editor scrub to confirm whether the current 99203 plus 87880 setup has any remaining modifier, NCCI, medical-necessity, or referring-provider defects.

Args · stage coding · day 16

{}

Result

{"ok": true, "issues": [], "n_issues": 0, "note": "scrub clean"}

#25 submit_claim The denial identified the failed urgent-care global code and invalid modifier on the rapid strep line; the claim has... ＋

Agent reasoning

The denial identified the failed urgent-care global code and invalid modifier on the rapid strep line; the claim has been corrected to office E/M 99203 plus 87880 without QW, with active coverage, correct provider taxonomy, diagnosis, Box 17b, and a clean scrub. This corrected coding differs from the prior denied submission, so I will resubmit the 837P now.

Args · stage remittance · day 32

{}

Result

{"ok": true, "result": "835_paid", "remit": {"remit_id": "era-a79a1ca59c", "status": "paid", "billed_cents": 30014, "allowed_cents": 30014, "paid_cents": 6068, "patient_resp_cents": 0, "contractual_cents": 23946, "claim_control_number": "CCN383348-2", "lines": [{"cpt": "87880", "billed_cents": 5000, "allowed_cents": 5000, "paid_cents": 375, "patient_resp_cents": 0, "contractual_cents": 4625}, {"cpt": "99203", "billed_cents": 25014, "allowed_cents": 25014, "paid_cents": 5693, "patient_resp_cents" …[truncated]

#26 post_remittance The corrected second submission has returned a paid 835 with no CARCs/RARCs and patient responsibility is $0. The... ＋

Agent reasoning

The corrected second submission has returned a paid 835 with no CARCs/RARCs and patient responsibility is $0. The remaining required action is to post the ERA payment and reconcile the account balance.

Args · stage closed_paid · day 32

{}

Result

{"ok": true, "posted": true, "note": "ERA posted; case closed paid"}