← Back to task

Trajectory · Claim #403065 · trial 1

GPT-5.5 openai

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

Reward

0.13

Coding

Tool calls

Final stage

closed_writeoff

Tool-by-tool trajectory · 56 tool calls

#0 portal_login I need to start by accessing the payer portal so I can verify Medicaid eligibility/coverage and any COB information... ＋

Agent reasoning

I need to start by accessing the payer portal so I can verify Medicaid eligibility/coverage and any COB information before coding or submitting the claim.

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 eligibility, COB, authorization, ERA, or claim-status work can be... ＋

Agent reasoning

I need to complete payer-portal access before eligibility, COB, authorization, ERA, or claim-status work can be performed. The OTP was already sent, so I will verify it now using the provided simulation code.

Args · stage intake · day 0

{"code": "000000"}

Result

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

#2 check_eligibility Before coding or submission, I need to confirm Medicaid NY fee-for-service coverage is active for the date of... ＋

Agent reasoning

Before coding or submission, I need to confirm Medicaid NY fee-for-service coverage is active for the date of service and identify any other coverage/COB information that could affect primary payer assignment.

Args · stage eligibility · day 0

{}

Result

{"ok": true, "coverages": [{"rank": "primary", "payer": "MEDICAID OF NEW YORK FS", "member_id": "MF71EAF3D0", "group": "GRP-61C7", "status": "active", "copay_cents": 2500, "deductible_remaining_cents": 0}, {"rank": "secondary", "payer": "SECONDARY SUPPLEMENTAL PLAN", "member_id": "SMF71EAF3D0", "status": "active"}], "cob_required": true, "note": "active coverage verified; secondary coverage present - coordinate benefits (set primary)"}

#3 coordinate_benefits Eligibility shows active Medicaid with a secondary supplemental plan, and the case requires COB resolution before... ＋

Agent reasoning

Eligibility shows active Medicaid with a secondary supplemental plan, and the case requires COB resolution before claim build. I will set Medicaid of New York FS as the primary payer because the 271 lists it as primary and the chart payer is correct.

Args · stage eligibility · day 0

{"primary_payer": "MEDICAID OF NEW YORK FS"}

Result

{"ok": true, "note": "primary set to MEDICAID OF NEW YORK FS"}

#4 read_chart I need to review the encounter documentation directly before assigning diagnoses, E/M level, or charges, focusing on... ＋

Agent reasoning

I need to review the encounter documentation directly before assigning diagnoses, E/M level, or charges, focusing on HPI, exam, assessment/plan ambiguity, orders, and any billable activities documented in the note.

Args · stage eligibility · day 0

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 16:32:00  |  End Time: 16:47:00  |  Length of Stay: 15 min  |  Reason: congestion + couching/ UTI  |  Visit type: UC - EST\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHPI: pt report here for STD Testing, nasal  congestion, cough and urine frequency  1 week , Onset:  acute, Severity:  moderate, Aggravated:  NONE, Relieved:  NONE 1 week denies moderate increased frequency denies Patient ha …[truncated]

#5 review_documentation Eligibility and COB are already resolved, so I need a coder documentation review before coding to identify any... ＋

Agent reasoning

Eligibility and COB are already resolved, so I need a coder documentation review before coding to identify any ambiguity that requires a provider query and to confirm what is supportable for billing from the note.

Args · stage documentation · day 0

{}

Result

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

#6 capture_charges Coverage/COB and documentation review are complete, and no provider query is open. Next I need to aggregate all... ＋

Agent reasoning

Coverage/COB and documentation review are complete, and no provider query is open. Next I need to aggregate all billable activities from the chart/charge sources before deriving CPT/HCPCS and E/M level.

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: Urinalysis, dipstick/tablet reagent, non-automated, w/o microscopy (CLIA-waived rapid test)."}, {"source": "order", "activity": "specimen_collection", "description": "Venous blood specimen collected (venipuncture)."}, {"source": "lab", "activity": "in_house_lab", "clia_waived": true, "description": "In-house lab performed: Urine pregnancy test, visual color comp …[truncated]

#7 kb_lookup_em_guidelines I need to level the established-patient urgent-care E/M from documented MDM rather than defaulting, especially... ＋

Agent reasoning

I need to level the established-patient urgent-care E/M from documented MDM rather than defaulting, especially because time is not usable and several tests were performed/ordered. I’m checking the 99213 criteria to confirm whether low MDM fits the chart before setting service lines.

Args · stage charge_capture · day 0

{"level": "99213"}

Result

{"code": "99213", "patient": "established", "mdm": "low", "summary": "2 self-limited OR 1 stable chronic; limited data; low risk."}

#8 kb_coding_guidelines Before setting service lines, I need payer/workflow coding rules for translating the captured urgent-care activities... ＋

Agent reasoning

Before setting service lines, I need payer/workflow coding rules for translating the captured urgent-care activities into CPT/HCPCS, including whether the urgent-care global activity should be billed as a case-rate rather than a separate E/M and lab lines. I will use the service-line guidance to avoid burning a submission with the wrong code family.

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]

#9 kb_coding_guidelines I need the payer/setting-specific urgent-care billing rule before setting service lines, because the prompt warns... ＋

Agent reasoning

I need the payer/setting-specific urgent-care billing rule before setting service lines, because the prompt warns urgent_care_global activity may require a UC case-rate HCPCS instead of a standard office E/M. I’ll look up the urgent-care coding guidance so I can map the captured activity correctly and avoid burning a submission.

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]

#10 get_status I need to see the detailed charge-capture output and any pending claim edits before committing CPT/HCPCS lines,... ＋

Agent reasoning

I need to see the detailed charge-capture output and any pending claim edits before committing CPT/HCPCS lines, since the feed contains activities rather than codes and there are 5 captured charges to map exactly.

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": "MEDICAID OF NEW YORK FS", "member_id": "MF71EAF3D0", "group": "GRP-61C7", "status": "active", "copay_cents": 2500, "deductible_remaining_cents": 0}, {"rank": "secondary", "payer": "SECONDARY SUPPLEMENTAL PLAN", "member_id": "SMF71EAF3D0", "status": "active"}], "cob_required": true, "cob_resolved": true, "wrong_payer_on_chart": false …[truncated]

#11 read_chart I need to re-read the progress note details before assigning ICD-10-CM and CPT/HCPCS, specifically to confirm the... ＋

Agent reasoning

I need to re-read the progress note details before assigning ICD-10-CM and CPT/HCPCS, specifically to confirm the documented symptoms, exam, any testing/treatment activity, and whether the E/M can be leveled from time or MDM. This will support accurate diagnosis sequencing and service-line selection before claim submission.

Args · stage charge_capture · day 0

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 16:32:00  |  End Time: 16:47:00  |  Length of Stay: 15 min  |  Reason: congestion + couching/ UTI  |  Visit type: UC - EST\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHPI: pt report here for STD Testing, nasal  congestion, cough and urine frequency  1 week , Onset:  acute, Severity:  moderate, Aggravated:  NONE, Relieved:  NONE 1 week denies moderate increased frequency denies Patient ha …[truncated]

#12 set_diagnoses Coverage/COB and charge capture are complete, and the next required claim element is Box 21 diagnoses. I am setting... ＋

Agent reasoning

Coverage/COB and charge capture are complete, and the next required claim element is Box 21 diagnoses. I am setting the ICD-10-CM diagnoses supported by the note: STD screening/high-risk unprotected intercourse plus documented nasal congestion, cough, urinary frequency, and suprapubic tenderness, sequenced with the screening reason first.

Args · stage coding · day 0

{"codes": ["Z11.3", "R09.81", "R05.9", "R35.0", "R10.819", "Z72.51"]}

Result

{"ok": true, "diagnoses": [{"sequence": 1, "code": "Z11.3"}, {"sequence": 2, "code": "R09.81"}, {"sequence": 3, "code": "R05.9"}, {"sequence": 4, "code": "R35.0"}, {"sequence": 5, "code": "R10.819"}, {"sequence": 6, "code": "Z72.51"}]}

#13 kb_lookup_cpt Before setting Box 24, I need to verify the urgent-care global/case-rate HCPCS descriptor because this payer/visit... ＋

Agent reasoning

Before setting Box 24, I need to verify the urgent-care global/case-rate HCPCS descriptor because this payer/visit type may require the urgent care global code instead of a standard E/M line. This will confirm the correct code family for the primary visit charge.

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"]}

#14 capture_charges Before setting Box 24, I need the actual captured charge activities behind the count of 5 so I can translate each... ＋

Agent reasoning

Before setting Box 24, I need the actual captured charge activities behind the count of 5 so I can translate each documented activity to the correct CPT/HCPCS and avoid missing or overbilling services. The status only shows the number captured, not the charge details.

Args · stage coding · day 0

{}

Result

{"ok": true, "charge_feed": [{"source": "lab", "activity": "in_house_lab", "clia_waived": true, "description": "In-house lab performed: Urinalysis, dipstick/tablet reagent, non-automated, w/o microscopy (CLIA-waived rapid test)."}, {"source": "order", "activity": "specimen_collection", "description": "Venous blood specimen collected (venipuncture)."}, {"source": "lab", "activity": "in_house_lab", "clia_waived": true, "description": "In-house lab performed: Urine pregnancy test, visual color comp …[truncated]

#15 kb_lookup_cpt I need to verify the CPT for the documented CLIA-waived in-house urinalysis dipstick/tablet reagent test before... ＋

Agent reasoning

I need to verify the CPT for the documented CLIA-waived in-house urinalysis dipstick/tablet reagent test before building Box 24 service lines. This should confirm the correct code description and whether it is a lab code that will need the QW modifier for CLIA-waived reporting.

Args · stage coding · day 0

{"code": "81002"}

Result

{"code": "81002", "found": true, "desc": "Urinalysis, dipstick/tablet reagent, non-automated, w/o microscopy", "category": "lab", "clia_waived": true, "keywords": ["urinalysis", "ua", "dipstick", "urine"]}

#16 kb_coding_guidelines Before setting Box 24, I need payer/service-line rules for urgent care global billing and whether ancillary... ＋

Agent reasoning

Before setting Box 24, I need payer/service-line rules for urgent care global billing and whether ancillary in-office labs require separate lines/modifiers under this payer. This will confirm whether to use the urgent-care case-rate HCPCS instead of an office E/M and how to report any waived lab charges.

Args · stage coding · 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]

#17 kb_lookup_payer_policy I need to know the payer-specific billing requirements before committing service lines, especially whether this NY... ＋

Agent reasoning

I need to know the payer-specific billing requirements before committing service lines, especially whether this NY Medicaid urgent-care encounter should be billed as a global urgent-care case-rate versus fee-for-service E/M/lab lines and whether any authorization/referring requirements apply.

Args · stage coding · day 0

{}

Result

{"payer": "MEDICAID OF NEW YORK FS", "payer_class": "MEDICAID", "policy": {"timely_filing_days": 90, "appeal_window_days": 60, "common_denials": ["CO-50", "CO-167", "CO-197"], "modifier_25_required_for_em_with_procedure": true}, "companion_guide": {"timely_filing_days": 199, "appeal_levels": ["plan_appeal", "state_fair_hearing"], "denial_timing_days": 39, "auth_required_services": ["70551", "70553", "72148", "20610", "93306"], "payer_id": "90209"}}

#18 kb_coding_guidelines I need to confirm how the payer wants urgent-care encounters billed before setting Box 24, especially whether the... ＋

Agent reasoning

I need to confirm how the payer wants urgent-care encounters billed before setting Box 24, especially whether the captured urgent-care global activity should be billed as S9083 rather than a separate office E/M and whether any special modifiers apply.

Args · stage coding · 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]

#19 capture_charges Before setting Box 24, I need the exact captured charge activities/units from the charge feed so I do not omit or... ＋

Agent reasoning

Before setting Box 24, I need the exact captured charge activities/units from the charge feed so I do not omit or overbill any of the 5 captured items. I am re-running charge capture specifically to retrieve the detailed activity list needed to map each item to CPT/HCPCS.

Args · stage coding · day 0

{}

Result

{"ok": true, "charge_feed": [{"source": "lab", "activity": "in_house_lab", "clia_waived": true, "description": "In-house lab performed: Urinalysis, dipstick/tablet reagent, non-automated, w/o microscopy (CLIA-waived rapid test)."}, {"source": "order", "activity": "specimen_collection", "description": "Venous blood specimen collected (venipuncture)."}, {"source": "lab", "activity": "in_house_lab", "clia_waived": true, "description": "In-house lab performed: Urine pregnancy test, visual color comp …[truncated]

#20 kb_lookup_cpt I need to verify each CPT/HCPCS I plan to place on Box 24 before committing service lines. Next I am confirming the... ＋

Agent reasoning

I need to verify each CPT/HCPCS I plan to place on Box 24 before committing service lines. Next I am confirming the urine pregnancy test code from the in-house CLIA-waived lab activity.

Args · stage coding · day 0

{"code": "81025"}

Result

{"code": "81025", "found": true, "desc": "Urine pregnancy test, visual color comparison", "category": "lab", "clia_waived": true, "keywords": ["pregnancy", "urine hcg", "hcg"]}

#21 get_status Before setting Box 24, I need the detailed captured-charge activities so I can map each one to the correct CPT/HCPCS... ＋

Agent reasoning

Before setting Box 24, I need the detailed captured-charge activities so I can map each one to the correct CPT/HCPCS rather than guessing from the narrative. I’ll inspect the current case state for the charge list and any remaining billing requirements.

Args · stage coding · day 0

{}

Result

{"stage": "coding", "sim_day": 0, "logged_in": true, "coverage_confirmed": true, "eligibility": {"checked": true, "coverages": [{"rank": "primary", "payer": "MEDICAID OF NEW YORK FS", "member_id": "MF71EAF3D0", "group": "GRP-61C7", "status": "active", "copay_cents": 2500, "deductible_remaining_cents": 0}, {"rank": "secondary", "payer": "SECONDARY SUPPLEMENTAL PLAN", "member_id": "SMF71EAF3D0", "status": "active"}], "cob_required": true, "cob_resolved": true, "wrong_payer_on_chart": false, "prima …[truncated]

#22 set_service_lines I’m ready to translate the captured urgent-care encounter and documented point-of-care/STD testing activity into... ＋

Agent reasoning

I’m ready to translate the captured urgent-care encounter and documented point-of-care/STD testing activity into billable CMS-1500 Box 24 lines. I’m using the Medicaid urgent-care global service rather than a separate office E/M, and linking each diagnostic test to the screening/urinary/high-risk indications documented in the note.

Args · stage coding · day 0

{"lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1, 2, 3, 4, 6], "place_of_service": "20"}, {"cpt": "81003", "modifiers": [], "units": 1, "dx_pointers": [4, 5], "place_of_service": "20"}, {"cpt": "81025", "modifiers": [], "units": 1, "dx_pointers": [1, 4,  …[truncated]

Result

{"ok": true, "service_lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1, 2, 3, 4, 6], "place_of_service": "20", "ndc": ""}, {"cpt": "81003", "modifiers": [], "units": 1, "dx_pointers": [4, 5], "place_of_service": "20", "ndc": ""}, {"cpt": "81025", "modifiers": [], "units": 1, "dx_pointers": [1, 4, 6], "place_of_service": "20", "ndc": ""}, {"cpt": "87491", "modifiers": [], "units": 1, "dx_pointers": [1, 6], "place_of_service": "20", "ndc": ""}, {"cpt": "87591", "modifiers": …[truncated]

#23 set_claim_header The remaining checklist item before scrub is Box 17b for ordered diagnostics/labs. The chart identifies RODRIGUEZ,... ＋

Agent reasoning

The remaining checklist item before scrub is Box 17b for ordered diagnostics/labs. The chart identifies RODRIGUEZ, LUIS DO as the rendering/ordering provider, so I will populate the claim header with his NPI and leave prior authorization blank because no listed service requires PA.

Args · stage coding · day 0

{"referring_npi": "1962435981", "prior_auth_number": ""}

Result

{"ok": true, "updated": ["referring_npi", "prior_auth_number"], "claim_header": {"onset_date": "", "referring_npi": "1962435981", "referring_name": "", "prior_auth_number": "", "accident_type": "", "claim_notes": ""}}

#24 run_scrub The claim has eligibility/COB resolved, diagnoses and service lines set, and the ordering provider NPI populated. I... ＋

Agent reasoning

The claim has eligibility/COB resolved, diagnoses and service lines set, and the ordering provider NPI populated. I will run the pre-submission scrub now to identify any payer, NCCI, modifier, medical-necessity, NDC, referral, or authorization issues before using a submission attempt.

Args · stage coding · day 0

{}

Result

{"ok": false, "issues": [{"edit": "medical_necessity", "severity": "error", "line": 3, "detail": "81025 not supported by linked diagnoses ['Z11.3', 'R35.0', 'Z72.51'] (NCD/LCD)"}], "n_issues": 1, "note": "scrub found blocking issues"}

#25 set_service_lines The scrub specifically flags the urine pregnancy test (81025) as not medically necessary for the linked diagnoses,... ＋

Agent reasoning

The scrub specifically flags the urine pregnancy test (81025) as not medically necessary for the linked diagnoses, and the chart does not document a pregnancy concern, missed menses, pregnancy status, or pregnancy-test result/medical indication. I will remove the unsupported 81025 line rather than force an unsupported diagnosis, while keeping the documented urgent-care, urinalysis, and STI testing lines.

Args · stage coding · day 0

{"lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1, 2, 3, 4, 6], "place_of_service": "20"}, {"cpt": "81003", "modifiers": [], "units": 1, "dx_pointers": [4, 5], "place_of_service": "20"}, {"cpt": "87491", "modifiers": [], "units": 1, "dx_pointers": [1, 6], …[truncated]

Result

{"ok": true, "service_lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1, 2, 3, 4, 6], "place_of_service": "20", "ndc": ""}, {"cpt": "81003", "modifiers": [], "units": 1, "dx_pointers": [4, 5], "place_of_service": "20", "ndc": ""}, {"cpt": "87491", "modifiers": [], "units": 1, "dx_pointers": [1, 6], "place_of_service": "20", "ndc": ""}, {"cpt": "87591", "modifiers": [], "units": 1, "dx_pointers": [1, 6], "place_of_service": "20", "ndc": ""}, {"cpt": "87661", "modifiers": [] …[truncated]

#26 run_scrub The claim has updated service lines but has not yet passed the pre-submission scrub. I need to run the scrub now to... ＋

Agent reasoning

The claim has updated service lines but has not yet passed the pre-submission scrub. I need to run the scrub now to identify the current blocking edits before using any submission attempt.

Args · stage coding · day 0

{}

Result

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

#27 submit_claim Eligibility/COB, provider identity, diagnoses, service lines, referring NPI, and scrub are already complete and... ＋

Agent reasoning

Eligibility/COB, provider identity, diagnoses, service lines, referring NPI, and scrub are already complete and clean. With no prior authorization required for these urgent-care/lab services and no previous submissions, the next step is to transmit the initial 837P and review the payer acknowledgments/remit outcome.

Args · stage denial · day 41

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-b790317939", "status": "denied", "billed_cents": 50000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 0, "claim_control_number": "CCN403065-1", "lines": [{"cpt": "S9083", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-11"}, {"cpt": "81003", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-11"}, {"cpt": "87491", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-11"}, {"cpt": "87591", "b …[truncated]

#28 kb_lookup_carc The denial is CO-11/N657 for diagnosis inconsistency, so I need to confirm the payer’s specific denial... ＋

Agent reasoning

The denial is CO-11/N657 for diagnosis inconsistency, so I need to confirm the payer’s specific denial definition/remedy before changing diagnosis sequencing or code selection. This should clarify whether the correction should target diagnosis specificity, dx-pointer linkage, or covered-condition criteria.

Args · stage denial · day 41

{"carc": "CO-11"}

Result

{"code": "CO-11", "found": true, "rarcs": [{"code": "N657", "narrative": "This should be billed with the appropriate code for these services."}], "narrative": "Diagnosis is inconsistent with the procedure.", "remedy": "Verify Box 21 ICD-10 codes match the services billed; ensure every Box 24 service line dx_pointers maps to a real Box 21 dx.", "appealable": "yes"}

#29 portal_download_era The claim denied for diagnosis/procedure inconsistency, and before changing codes I need the full ERA/EOB detail to... ＋

Agent reasoning

The claim denied for diagnosis/procedure inconsistency, and before changing codes I need the full ERA/EOB detail to identify whether the payer rejected a specific line or diagnosis linkage versus the whole claim. I will download the ERA to confirm the exact adjudication details and any line-level remarks before recoding and resubmitting.

Args · stage denial · day 41

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN403065-1\n  Status: DENIED\n  Billed:      $500.00\n  Allowed:     $0.00\n  Paid:        $0.00\n  Pt resp:     $0.00\n  Contractual: $0.00\n  CARC: CO-11\n  RARC: N657\n    S9083: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    81003: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    87491: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    87591: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    87661: billed $100.00 paid …[truncated]

#30 kb_lookup_payer_policy The denial says the diagnosis set is inconsistent with the procedures, so before burning a resubmission I’m checking... ＋

Agent reasoning

The denial says the diagnosis set is inconsistent with the procedures, so before burning a resubmission I’m checking the payer’s Medicaid companion/policy rules for urgent-care case-rate and lab diagnosis requirements. I expect this to identify whether S9083 requires a symptom/medical complaint primary diagnosis rather than preventive STD screening as Box 21 primary.

Args · stage denial · day 41

{}

Result

{"payer": "MEDICAID OF NEW YORK FS", "payer_class": "MEDICAID", "policy": {"timely_filing_days": 90, "appeal_window_days": 60, "common_denials": ["CO-50", "CO-167", "CO-197"], "modifier_25_required_for_em_with_procedure": true}, "companion_guide": {"timely_filing_days": 199, "appeal_levels": ["plan_appeal", "state_fair_hearing"], "denial_timing_days": 39, "auth_required_services": ["70551", "70553", "72148", "20610", "93306"], "payer_id": "90209"}}

#31 read_chart The payer denied for diagnosis/procedure inconsistency, so I need to re-read the encounter documentation... ＋

Agent reasoning

The payer denied for diagnosis/procedure inconsistency, so I need to re-read the encounter documentation specifically for the documented reasons for each billed service and correct ICD sequencing/pointers rather than resubmit unchanged. I will reopen the progress note to reassess whether screening, URI symptoms, urinary symptoms, or suprapubic tenderness should drive the primary diagnosis and lab line diagnoses.

Args · stage denial · day 41

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 16:32:00  |  End Time: 16:47:00  |  Length of Stay: 15 min  |  Reason: congestion + couching/ UTI  |  Visit type: UC - EST\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHPI: pt report here for STD Testing, nasal  congestion, cough and urine frequency  1 week , Onset:  acute, Severity:  moderate, Aggravated:  NONE, Relieved:  NONE 1 week denies moderate increased frequency denies Patient ha …[truncated]

#32 create_provider_query The CO-11 denial points to diagnosis/procedure inconsistency, and the chart is internally ambiguous because it... ＋

Agent reasoning

The CO-11 denial points to diagnosis/procedure inconsistency, and the chart is internally ambiguous because it documents urinary frequency/suprapubic tenderness while also stating the patient denies genitourinary symptoms. I need provider clarification before recoding the UA/STI testing diagnoses and dx pointers so we do not burn another submission attempt.

Args · stage denial · day 41

{"topic": "diagnosis clarification for urinary/STI testing medical necessity", "question": "For DOS 2024-09-15, please clarify the intended diagnoses/clinical indication(s): the HPI documents urinary frequency x1 week and exam notes suprapubic tenderness, but the STD screening hi …[truncated]

Result

{"ok": true, "query_id": "q-40ce582cba", "note": "query routed to provider; awaiting response"}

#33 resolve_provider_query The claim denied for diagnosis inconsistency, and an open provider query was created specifically to clarify the... ＋

Agent reasoning

The claim denied for diagnosis inconsistency, and an open provider query was created specifically to clarify the urinary/STI diagnosis documentation. I need the provider’s response before changing ICD-10 sequencing or specificity and risking another submission.

Args · stage denial · day 43

{"query_id": "q-40ce582cba"}

Result

{"ok": true, "query_id": "q-40ce582cba", "doc_state": "provider-query-resolved", "resolution": "Provider clarified specificity/laterality and confirmed medical necessity; documentation now supports final coding."}

#34 review_documentation The denial is for diagnosis/procedure inconsistency, and the provider query has now been resolved. I need an updated... ＋

Agent reasoning

The denial is for diagnosis/procedure inconsistency, and the provider query has now been resolved. I need an updated coder documentation review incorporating that clarification before changing diagnosis sequencing and risking a second submission.

Args · stage denial · day 43

{}

Result

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

#35 set_diagnoses The denial is for diagnosis/procedure inconsistency, and the previously submitted claim sequenced STI screening... ＋

Agent reasoning

The denial is for diagnosis/procedure inconsistency, and the previously submitted claim sequenced STI screening first while the chart’s primary SNOMED/visit reason supports a urinary complaint with URI/STI-screening symptoms secondary. I am correcting Box 21 by adding the omitted urinary primary diagnosis and sequencing symptom/encounter codes to match the documented visit before any resubmission.

Args · stage coding · day 43

{"codes": ["R30.0", "R35.0", "R10.819", "Z11.3", "Z72.51", "R09.81", "R05.9"]}

Result

{"ok": true, "diagnoses": [{"sequence": 1, "code": "R30.0"}, {"sequence": 2, "code": "R35.0"}, {"sequence": 3, "code": "R10.819"}, {"sequence": 4, "code": "Z11.3"}, {"sequence": 5, "code": "Z72.51"}, {"sequence": 6, "code": "R09.81"}, {"sequence": 7, "code": "R05.9"}]}

#36 portal_download_era The claim denied for diagnosis/procedure inconsistency, and before changing coding I need the full ERA/EOB detail to... ＋

Agent reasoning

The claim denied for diagnosis/procedure inconsistency, and before changing coding I need the full ERA/EOB detail to confirm whether the denial applies to all lines or a specific service/diagnosis linkage. This will guide a targeted correction without wasting a remaining submission.

Args · stage coding · day 43

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN403065-1\n  Status: DENIED\n  Billed:      $500.00\n  Allowed:     $0.00\n  Paid:        $0.00\n  Pt resp:     $0.00\n  Contractual: $0.00\n  CARC: CO-11\n  RARC: N657\n    S9083: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    81003: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    87491: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    87591: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    87661: billed $100.00 paid …[truncated]

#37 kb_lookup_carc The ERA denied the entire claim with CO-11/N657, indicating diagnosis inconsistency with the billed procedures. I... ＋

Agent reasoning

The ERA denied the entire claim with CO-11/N657, indicating diagnosis inconsistency with the billed procedures. I need to confirm the payer-standard meaning and recommended correction path before changing the diagnosis pointers and resubmitting.

Args · stage coding · day 43

{"carc": "CO-11"}

Result

{"code": "CO-11", "found": true, "rarcs": [{"code": "N657", "narrative": "This should be billed with the appropriate code for these services."}], "narrative": "Diagnosis is inconsistent with the procedure.", "remedy": "Verify Box 21 ICD-10 codes match the services billed; ensure every Box 24 service line dx_pointers maps to a real Box 21 dx.", "appealable": "yes"}

#38 set_service_lines The denial is for diagnosis/procedure inconsistency, and the current line-level diagnosis pointers are mismatched:... ＋

Agent reasoning

The denial is for diagnosis/procedure inconsistency, and the current line-level diagnosis pointers are mismatched: the urinalysis points to STI screening/high-risk codes, while the STI NAATs point to urinary/congestion codes. I will correct the Box 24 diagnosis pointers so each service line links to the documented condition that supports it before re-scrubbing and resubmitting.

Args · stage coding · day 43

{"lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1, 2, 3, 4, 5, 6, 7], "place_of_service": "20"}, {"cpt": "81003", "modifiers": [], "units": 1, "dx_pointers": [1, 2, 3], "place_of_service": "20"}, {"cpt": "87491", "modifiers": [], "units": 1, "dx_pointers" …[truncated]

Result

{"ok": true, "service_lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1, 2, 3, 4, 5, 6, 7], "place_of_service": "20", "ndc": ""}, {"cpt": "81003", "modifiers": [], "units": 1, "dx_pointers": [1, 2, 3], "place_of_service": "20", "ndc": ""}, {"cpt": "87491", "modifiers": [], "units": 1, "dx_pointers": [4, 5], "place_of_service": "20", "ndc": ""}, {"cpt": "87591", "modifiers": [], "units": 1, "dx_pointers": [4, 5], "place_of_service": "20", "ndc": ""}, {"cpt": "87661", "modif …[truncated]

#39 run_scrub The prior denial was diagnosis/procedure inconsistency, and the claim has now been re-sequenced with urinary... ＋

Agent reasoning

The prior denial was diagnosis/procedure inconsistency, and the claim has now been re-sequenced with urinary symptoms primary before resubmission. I need to run a fresh pre-submission scrub on the revised diagnosis sequencing and existing service-line dx pointers before using another limited submission attempt.

Args · stage coding · day 43

{}

Result

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

#40 read_chart The claim denied for diagnosis/procedure inconsistency, so I need to re-open the source progress note and re-derive... ＋

Agent reasoning

The claim denied for diagnosis/procedure inconsistency, so I need to re-open the source progress note and re-derive the supported ICD-10 sequencing from the documented symptoms and STD-screening context before using another submission attempt.

Args · stage denial · day 84

{"section": "progress_note"}

Result

{"ok": false, "error": "Your corrected claim is scrubbed CLEAN and differs from what you already submitted - TRANSMIT IT NOW: submit_claim. You have 2 of 3 attempts left. Re-coding, lookups, and re-scrubbing are paused until you resubmit this claim.", "must_call_next": "submit_claim"}

#41 submit_claim The corrected claim has already been updated, scrubbed clean, and confirmed to differ from the previously denied... ＋

Agent reasoning

The corrected claim has already been updated, scrubbed clean, and confirmed to differ from the previously denied submission. Since re-coding and additional lookups are paused until resubmission, the next required step is to transmit the corrected 837P and obtain payer acknowledgments/adjudication.

Args · stage denial · day 84

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-3a3383a035", "status": "denied", "billed_cents": 50000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 0, "claim_control_number": "CCN403065-2", "lines": [{"cpt": "S9083", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-11"}, {"cpt": "81003", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-11"}, {"cpt": "87491", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-11"}, {"cpt": "87591", "b …[truncated]

#42 kb_lookup_payer_policy The denial is diagnosis/procedure consistency across the whole claim after symptom and screening-only ICD sequencing... ＋

Agent reasoning

The denial is diagnosis/procedure consistency across the whole claim after symptom and screening-only ICD sequencing failed. I need to confirm this payer’s Medicaid FS rules for urgent-care global billing and covered diagnosis linkage before using the final submission attempt.

Args · stage denial · day 84

{}

Result

{"payer": "MEDICAID OF NEW YORK FS", "payer_class": "MEDICAID", "policy": {"timely_filing_days": 90, "appeal_window_days": 60, "common_denials": ["CO-50", "CO-167", "CO-197"], "modifier_25_required_for_em_with_procedure": true}, "companion_guide": {"timely_filing_days": 199, "appeal_levels": ["plan_appeal", "state_fair_hearing"], "denial_timing_days": 39, "auth_required_services": ["70551", "70553", "72148", "20610", "93306"], "payer_id": "90209"}}

#43 read_chart The denial is specifically for diagnosis/procedure inconsistency, and two prior submissions used symptom/screening... ＋

Agent reasoning

The denial is specifically for diagnosis/procedure inconsistency, and two prior submissions used symptom/screening diagnoses that may not match the SNOMED/problem-list intent. I will re-open the chart/problem details to re-derive the ICD-10-CM set before using the final submission attempt.

Args · stage denial · day 84

{"section": "problem_list_snomed"}

Result

{"section": "problem_list_snomed", "body": "Diagnoses are recorded in SNOMED CT and are NOT auto-translated - read each documented condition and assign the specific ICD-10-CM yourself (choose the right laterality/acuity/specificity from the note, then verify the code with kb_lookup_icd10 code=...):\n  - SNOMED 49650001 (primary): see note\n  - SNOMED 305058001: see note\n  - SNOMED 444451006: see note\n  - SNOMED 309406008: see note\n  - SNOMED 454791000124107: see note\n  - SNOMED 444433005: se …[truncated]

#44 portal_download_era The claim is currently denied for CO-11 diagnosis inconsistency and we have only one submission left, so I need to... ＋

Agent reasoning

The claim is currently denied for CO-11 diagnosis inconsistency and we have only one submission left, so I need to review the full ERA/EOB details before changing diagnosis coding. This should identify whether the denial applies to a specific line such as the urgent-care global or lab services and help avoid another incorrect resubmission.

Args · stage denial · day 84

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN403065-2\n  Status: DENIED\n  Billed:      $500.00\n  Allowed:     $0.00\n  Paid:        $0.00\n  Pt resp:     $0.00\n  Contractual: $0.00\n  CARC: CO-11\n  RARC: N657\n    S9083: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    81003: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    87491: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    87591: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    87661: billed $100.00 paid …[truncated]

#45 kb_lookup_icd10 The ERA denial is CO-11 wrong diagnosis, and the chart’s primary SNOMED plus visit reason/urinary frequency suggests... ＋

Agent reasoning

The ERA denial is CO-11 wrong diagnosis, and the chart’s primary SNOMED plus visit reason/urinary frequency suggests the prior symptom-only coding may have missed a documented UTI diagnosis. I am verifying the likely ICD-10-CM code before changing the final remaining resubmission.

Args · stage denial · day 84

{"code": "N39.0"}

Result

{"code": "N39.0", "found": true, "description": "Urinary tract infection, site not specified", "note": "Description only - confirm this is the specific code the documentation supports before committing it."}

#46 portal_download_era The denial states the diagnosis set is inconsistent with the procedures, so I need to read the full ERA details... ＋

Agent reasoning

The denial states the diagnosis set is inconsistent with the procedures, so I need to read the full ERA details before changing the last remaining submission. I expect the ERA to clarify whether the inconsistency is tied to the urgent-care global service or the lab lines/diagnosis pointers.

Args · stage denial · day 84

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN403065-2\n  Status: DENIED\n  Billed:      $500.00\n  Allowed:     $0.00\n  Paid:        $0.00\n  Pt resp:     $0.00\n  Contractual: $0.00\n  CARC: CO-11\n  RARC: N657\n    S9083: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    81003: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    87491: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    87591: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-11]\n    87661: billed $100.00 paid …[truncated]

#47 kb_lookup_icd10 The denial is CO-11 diagnosis inconsistent with procedures, and the current symptom-only diagnosis set may not match... ＋

Agent reasoning

The denial is CO-11 diagnosis inconsistent with procedures, and the current symptom-only diagnosis set may not match the chart’s documented “UTI” reason for visit. I will verify N39.0 before recoding the primary diagnosis to the documented urinary tract infection rather than resubmitting another symptom-only set.

Args · stage denial · day 84

{"code": "N39.0"}

Result

{"code": "N39.0", "found": true, "description": "Urinary tract infection, site not specified", "note": "Description only - confirm this is the specific code the documentation supports before committing it."}

#48 kb_lookup_carc The current denial is CO-11/N657 for diagnosis inconsistency, and before using the last submission attempt I need... ＋

Agent reasoning

The current denial is CO-11/N657 for diagnosis inconsistency, and before using the last submission attempt I need the payer-remedy guidance for this denial family. I will look up CO-11 to confirm the corrective action focus before re-deriving the diagnosis set from the chart.

Args · stage denial · day 84

{"carc": "CO-11"}

Result

{"code": "CO-11", "found": true, "rarcs": [{"code": "N657", "narrative": "This should be billed with the appropriate code for these services."}], "narrative": "Diagnosis is inconsistent with the procedure.", "remedy": "Verify Box 21 ICD-10 codes match the services billed; ensure every Box 24 service line dx_pointers maps to a real Box 21 dx.", "appealable": "yes"}

#49 read_chart The claim is denied for diagnosis/procedure inconsistency after two different symptom/screening diagnosis sequences,... ＋

Agent reasoning

The claim is denied for diagnosis/procedure inconsistency after two different symptom/screening diagnosis sequences, so I need to re-open the source documentation to identify any unsupported diagnosis (e.g., dysuria) and whether the provider documented an actual UTI versus only urinary frequency/screening. I will review the full progress note again focusing on the assessment/HPI language that supports the corrected ICD-10 set before using the final submission attempt.

Args · stage denial · day 84

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 16:32:00  |  End Time: 16:47:00  |  Length of Stay: 15 min  |  Reason: congestion + couching/ UTI  |  Visit type: UC - EST\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHPI: pt report here for STD Testing, nasal  congestion, cough and urine frequency  1 week , Onset:  acute, Severity:  moderate, Aggravated:  NONE, Relieved:  NONE 1 week denies moderate increased frequency denies Patient ha …[truncated]

#50 kb_lookup_payer_policy The denial is diagnosis/procedure consistency after two different diagnosis orderings, so I need payer-specific... ＋

Agent reasoning

The denial is diagnosis/procedure consistency after two different diagnosis orderings, so I need payer-specific rules before using the final submission attempt. I will check the NY Medicaid FS companion/policy guidance for urgent-care case-rate and lab diagnosis requirements, especially S9083 and STI/urinalysis linkages.

Args · stage coding · day 84

{}

Result

{"payer": "MEDICAID OF NEW YORK FS", "payer_class": "MEDICAID", "policy": {"timely_filing_days": 90, "appeal_window_days": 60, "common_denials": ["CO-50", "CO-167", "CO-197"], "modifier_25_required_for_em_with_procedure": true}, "companion_guide": {"timely_filing_days": 199, "appeal_levels": ["plan_appeal", "state_fair_hearing"], "denial_timing_days": 39, "auth_required_services": ["70551", "70553", "72148", "20610", "93306"], "payer_id": "90209"}}

#51 set_diagnoses The denial is specifically CO-11 for diagnosis/procedure inconsistency, and the prior attempts used only urinary... ＋

Agent reasoning

The denial is specifically CO-11 for diagnosis/procedure inconsistency, and the prior attempts used only urinary symptoms/screening diagnoses despite the visit reason and SNOMED list indicating UTI. I need to update Box 21 to include the documented UTI diagnosis as the primary condition before using the final submission attempt.

Args · stage coding · day 84

{"codes": ["N39.0", "R35.0", "R10.819", "Z11.3", "Z72.51", "R09.81", "R05.9"]}

Result

{"ok": true, "diagnoses": [{"sequence": 1, "code": "N39.0"}, {"sequence": 2, "code": "R35.0"}, {"sequence": 3, "code": "R10.819"}, {"sequence": 4, "code": "Z11.3"}, {"sequence": 5, "code": "Z72.51"}, {"sequence": 6, "code": "R09.81"}, {"sequence": 7, "code": "R05.9"}]}

#52 run_scrub The diagnosis set has been changed after the CO-11 denial, and this final submission must not be sent until the... ＋

Agent reasoning

The diagnosis set has been changed after the CO-11 denial, and this final submission must not be sent until the updated ICD sequencing and existing service lines pass payer/NCCI/medical-necessity edits. I will run the pre-submission scrub now to confirm the corrected claim is clean before using the last submission attempt.

Args · stage denial · day 125

{}

Result

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

#53 portal_download_era The second submission denied CO-11 for diagnosis/procedure inconsistency, and before using the final submission I... ＋

Agent reasoning

The second submission denied CO-11 for diagnosis/procedure inconsistency, and before using the final submission I need the full ERA/EOB details to identify which procedure/diagnosis pairing the payer rejected rather than guessing. I will download the ERA to review the payer’s exact adjudication detail and any line-level messages.

Args · stage closed_writeoff · day 125

{}

Result

{"ok": false, "error": "Your corrected claim is scrubbed CLEAN and differs from what you already submitted - TRANSMIT IT NOW: submit_claim. You have 1 of 3 attempts left. Re-coding, lookups, and re-scrubbing are paused until you resubmit this claim.", "must_call_next": "submit_claim"}

#54 submit_claim The corrected diagnosis set has already been applied, the claim scrub is clean, and it differs from both prior... ＋

Agent reasoning

The corrected diagnosis set has already been applied, the claim scrub is clean, and it differs from both prior denied submissions. With only one submission attempt remaining, the next required step is to transmit the corrected 837P and obtain payer acknowledgment/adjudication.

Args · stage None · day None

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-4c368f4377", "status": "denied", "billed_cents": 50000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 0, "claim_control_number": "CCN403065-3", "lines": [{"cpt": "S9083", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-11"}, {"cpt": "81003", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-11"}, {"cpt": "87491", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-11"}, {"cpt": "87591", "b …[truncated]

#55 write_off All three allowed payer submissions have been used and the claim continues to deny for CO-11. The case instructions... ＋

Agent reasoning

All three allowed payer submissions have been used and the claim continues to deny for CO-11. The case instructions state there are no remaining resubmission opportunities and direct that the balance be written off to close the case.

Args · stage None · day None

{}

Result

{"ok": true, "note": "balance written off; case closed"}