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Trajectory · Claim #56095 · trial 2

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 · 25 tool calls

#0 portal_login I need payer portal access before I can verify active Medicaid coverage and later retrieve remittance/denial details... ＋

Agent reasoning

I need payer portal access before I can verify active Medicaid coverage and later retrieve remittance/denial details if needed. I’m starting the portal login workflow, which should trigger the OTP step.

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 verifying coverage and any payer-specific requirements. The OTP was... ＋

Agent reasoning

I need to complete payer portal access before verifying coverage and any payer-specific requirements. The OTP was already sent, so I will verify it now to continue eligibility and claim workflow steps.

Args · stage intake · day 0

{"code": "000000"}

Result

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

#2 check_eligibility Before coding or submitting, I need to verify the member has active coverage for the DOS and identify any... ＋

Agent reasoning

Before coding or submitting, I need to verify the member has active coverage for the DOS and identify any COB/primary-payer issues from the 271 response.

Args · stage eligibility · day 0

{}

Result

{"ok": true, "coverages": [{"rank": "primary", "payer": "HEALTHFIRST OF NEW YORK GR", "member_id": "MD9134E2A6", "group": "GRP-F852", "status": "active", "copay_cents": 2500, "deductible_remaining_cents": 0}], "cob_required": false, "note": "active coverage verified"}

#3 read_chart I need to perform the required coder documentation review before selecting diagnoses and E/M level. I will open the... ＋

Agent reasoning

I need to perform the required coder documentation review before selecting diagnoses and E/M level. I will open the progress note to confirm the HPI, exam, assessment, orders, and whether any billable procedures or ambiguity require a provider query.

Args · stage eligibility · day 0

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 20:03:00  |  End Time: 20:18:00  |  Length of Stay: 15 min  |  Reason: abdominal pain  |  Visit type: UC - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHistory: 28 yo male c/o abdominal pain x 1 day; Endorses N and 5 episodes of D. Denies vomiting, or cold sx.\n[MUSCULOSKELETAL:] normal, no swelling or deformity\n[SKIN:] no rashes, normal, good turgor, warm and dry\n[ABDOMEN:] bowel s …[truncated]

#4 review_documentation Eligibility/COB is already resolved, so I’m moving to formal coder documentation review before selecting diagnoses... ＋

Agent reasoning

Eligibility/COB is already resolved, so I’m moving to formal coder documentation review before selecting diagnoses or E/M level. I expect this to identify any documentation gaps or ambiguities that require a provider query, such as the conflicting age/sex in the note versus registration and the unspecified gastroenteritis assessment.

Args · stage documentation · day 0

{}

Result

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

#5 capture_charges Documentation review found no query needed, so the next step is to aggregate all billable activities from the... ＋

Agent reasoning

Documentation review found no query needed, so the next step is to aggregate all billable activities from the chart/charge feed before assigning CPT/HCPCS. I expect this to identify the professional service charge and confirm whether any labs, drugs, supplies, or procedures were documented.

Args · stage charge_capture · day 0

{}

Result

{"ok": true, "charge_feed": [{"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-or-time guidelines (kb_lookup_em_guidelines).", "activity": "evaluation_and_management"}], "note": "The feed lists clinical activity, not codes - assign each CPT/HCPCS yourself (verify a chosen code with kb_ …[truncated]

#6 kb_lookup_em_guidelines The only captured activity is a new urgent-care E/M visit. I need to verify whether the documented acute... ＋

Agent reasoning

The only captured activity is a new urgent-care E/M visit. I need to verify whether the documented acute uncomplicated gastroenteritis/abdominal-pain visit supports new-patient low-complexity MDM before setting CPT 99203.

Args · stage charge_capture · day 0

{"level": "99203"}

Result

{"code": "99203", "patient": "new", "mdm": "low", "summary": "1 stable chronic OR 2 self-limited; limited data review; low risk."}

#7 kb_lookup_icd10 I need to translate the documented primary SNOMED diagnosis of gastroenteritis to the correct ICD-10-CM code before... ＋

Agent reasoning

I need to translate the documented primary SNOMED diagnosis of gastroenteritis to the correct ICD-10-CM code before setting Box 21; I am verifying the code description for the most appropriate unspecified gastroenteritis code rather than relying on the SNOMED text alone.

Args · stage charge_capture · day 0

{"code": "K52.9"}

Result

{"code": "K52.9", "found": false, "note": "Description only - confirm this is the specific code the documentation supports before committing it."}

#8 kb_coding_guidelines The charge feed captured one clinical activity but no code, and this is an urgent-care new-patient visit. I need the... ＋

Agent reasoning

The charge feed captured one clinical activity but no code, and this is an urgent-care new-patient visit. I need the service-line rules for urgent-care billing to determine whether this payer expects a global UC HCPCS case-rate versus a standard E/M before I set Box 24.

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 The prompt warns that urgent-care charge-feed activity may require a payer-specific urgent care global/case-rate... ＋

Agent reasoning

The prompt warns that urgent-care charge-feed activity may require a payer-specific urgent care global/case-rate HCPCS rather than a standard E/M. I need to check the payer/service-line guidance before setting Box 24 so I do not burn a submission with the wrong code family.

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 kb_lookup_cpt The encounter documents a new urgent-care evaluation for acute gastroenteritis symptoms with no orders, procedures,... ＋

Agent reasoning

The encounter documents a new urgent-care evaluation for acute gastroenteritis symptoms with no orders, procedures, drugs, or supplies. I need to verify the candidate new-patient E/M CPT code before setting Box 24 service lines.

Args · stage charge_capture · day 0

{"code": "99203"}

Result

{"code": "99203", "found": true, "desc": "Office/outpatient E/M, NEW patient, low MDM", "category": "em_new", "patient": "new", "mdm": "low"}

#11 set_diagnoses The documented primary condition is gastroenteritis without a specified infectious organism, complication, or... ＋

Agent reasoning

The documented primary condition is gastroenteritis without a specified infectious organism, complication, or alternate etiology; the ICD-10-CM code K52.9 was already verified. I will set the diagnosis in Box 21 primary-first so the service line can point to it.

Args · stage coding · day 0

{"codes": ["K52.9"]}

Result

{"ok": true, "diagnoses": [{"sequence": 1, "code": "K52.9"}]}

#12 kb_lookup_cpt The encounter is an urgent-care new patient visit with one captured charge and no separate orders, drugs, labs, or... ＋

Agent reasoning

The encounter is an urgent-care new patient visit with one captured charge and no separate orders, drugs, labs, or supplies. Before setting Box 24, I need to verify the HCPCS urgent-care global case-rate code that may be required instead of a standard office E/M for this payer/setting.

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_payer_policy Before setting Box 24, I need to confirm this payer’s professional billing requirements for urgent care encounters,... ＋

Agent reasoning

Before setting Box 24, I need to confirm this payer’s professional billing requirements for urgent care encounters, especially whether Healthfirst Medicaid expects the urgent-care global case-rate HCPCS rather than a standard new-patient E/M code and whether any auth/referring rules apply.

Args · stage coding · day 0

{}

Result

{"payer": "HEALTHFIRST OF NEW YORK GR", "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": 266, "appeal_levels": ["plan_appeal", "state_fair_hearing"], "denial_timing_days": 36, "auth_required_services": ["70551", "70553", "72148", "20610", "93306"], "payer_id": "44736"}}

#14 set_service_lines The captured urgent-care encounter appears to be the global urgent-care case-rate service, with no separately... ＋

Agent reasoning

The captured urgent-care encounter appears to be the global urgent-care case-rate service, with no separately documented procedures, labs, drugs, or imaging. I will set the Box 24 service line to S9083 with POS 20 and link it to the gastroenteritis diagnosis already set.

Args · stage coding · day 0

{"lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20"}]}

Result

{"ok": true, "service_lines": [{"cpt": "S9083", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20", "ndc": ""}]}

#15 run_scrub Eligibility, COB, documentation review, charges, diagnosis, provider identity, and urgent-care global service line... ＋

Agent reasoning

Eligibility, COB, documentation review, charges, diagnosis, provider identity, and urgent-care global service line are already set. There are no ordered diagnostics/drugs/prior-auth services requiring Box 17b, NDC, or Box 23, so the next safe step is to run the pre-submission scrub before using a claim submission attempt.

Args · stage coding · day 0

{}

Result

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

#16 submit_claim Coverage, COB, provider identity, diagnosis, urgent-care global service line, and scrub are already complete and... ＋

Agent reasoning

Coverage, COB, provider identity, diagnosis, urgent-care global service line, and scrub are already complete and clean. There are no ordered diagnostics/drugs requiring referring NPI, NDC, or prior authorization, so the next appropriate step is to submit the first 837P and review payer acknowledgments/remittance.

Args · stage denial · day 38

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-b4a3b07258", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN56095-1", "lines": [{"cpt": "S9083", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-16", "rarcs": ["M51"]}], "carcs": ["CO-16"], "rarcs": ["M51"], "posted": false, "transaction": "835"}, "denial": {"denial_id": "den-47dc6d2ff4", "stage": "adjudication", "s …[truncated]

#17 kb_lookup_carc The payer denied the submitted S9083 line with CO-16/M51, so I need to confirm the denial meaning and remedy before... ＋

Agent reasoning

The payer denied the submitted S9083 line with CO-16/M51, so I need to confirm the denial meaning and remedy before changing the claim. This will guide whether the correction should be a CPT replacement, added documentation element, or another claim-field fix.

Args · stage denial · day 38

{"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"}

#18 portal_download_era The payer denied line 1 for an invalid/unsupported procedure code, and before changing/resubmitting I need to review... ＋

Agent reasoning

The payer denied line 1 for an invalid/unsupported procedure code, and before changing/resubmitting I need to review the full ERA/EOB to confirm the adjudication details and any payer-specific remark beyond the summarized CO-16/M51.

Args · stage denial · day 38

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN56095-1\n  Status: DENIED\n  Billed:      $100.00\n  Allowed:     $0.00\n  Paid:        $0.00\n  Pt resp:     $0.00\n  Contractual: $100.00\n  CARC: CO-16\n  RARC: M51\n    S9083: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-16 M51]", "era": {"remit_id": "era-b4a3b07258", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN56095-1", "line …[truncated]

#19 read_chart The denial says the billed urgent-care global code S9083 is unsupported for this documented encounter, so I need to... ＋

Agent reasoning

The denial says the billed urgent-care global code S9083 is unsupported for this documented encounter, so I need to re-open the progress note and verify the actual documented face-to-face service, MDM elements, orders, time, and any missed billable services before choosing a replacement CPT.

Args · stage denial · day 38

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 20:03:00  |  End Time: 20:18:00  |  Length of Stay: 15 min  |  Reason: abdominal pain  |  Visit type: UC - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHistory: 28 yo male c/o abdominal pain x 1 day; Endorses N and 5 episodes of D. Denies vomiting, or cold sx.\n[MUSCULOSKELETAL:] normal, no swelling or deformity\n[SKIN:] no rashes, normal, good turgor, warm and dry\n[ABDOMEN:] bowel s …[truncated]

#20 kb_lookup_cpt The denial specifically rejects S9083 as unsupported, so I need to replace it with the documented new-patient urgent... ＋

Agent reasoning

The denial specifically rejects S9083 as unsupported, so I need to replace it with the documented new-patient urgent care E/M code. Based on the chart, the likely corrected code is 99203, and I am verifying the CPT description before updating the service line.

Args · stage denial · day 38

{"code": "99203"}

Result

{"code": "99203", "found": true, "desc": "Office/outpatient E/M, NEW patient, low MDM", "category": "em_new", "patient": "new", "mdm": "low"}

#21 set_service_lines The denial specifically invalidated S9083 as unsupported/not documented, and the chart supports a new-patient... ＋

Agent reasoning

The denial specifically invalidated S9083 as unsupported/not documented, and the chart supports a new-patient urgent-care E/M for acute gastroenteritis with low MDM. I am replacing the denied global UC code with the documented new-patient E/M code 99203 before re-scrubbing and resubmitting.

Args · stage coding · day 38

{"lines": [{"cpt": "99203", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20"}]}

Result

{"ok": true, "service_lines": [{"cpt": "99203", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20", "ndc": ""}]}

#22 run_scrub The denied S9083 urgent-care global line has been replaced with a documented new-patient E/M line, so I need to... ＋

Agent reasoning

The denied S9083 urgent-care global line has been replaced with a documented new-patient E/M line, so I need to validate the corrected claim before using another submission attempt. I expect the scrub to confirm CPT validity, POS, diagnosis linkage, medical necessity, and absence of missing auth/referring/NDC issues.

Args · stage coding · day 38

{}

Result

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

#23 submit_claim The prior denial was for unsupported S9083; I have replaced it with the chart-supported new-patient urgent care E/M... ＋

Agent reasoning

The prior denial was for unsupported S9083; I have replaced it with the chart-supported new-patient urgent care E/M 99203 linked to K52.9, with no ordered services, drugs, or auth/referring requirements. The corrected claim has passed scrub clean and differs from the denied coding, so the next step is to resubmit the corrected 837P.

Args · stage remittance · day 76

{}

Result

{"ok": true, "result": "835_paid", "remit": {"remit_id": "era-51619b9368", "status": "paid", "billed_cents": 12600, "allowed_cents": 12500, "paid_cents": 12500, "patient_resp_cents": 0, "contractual_cents": 100, "claim_control_number": "CCN56095-2", "lines": [{"cpt": "99203", "billed_cents": 12600, "allowed_cents": 12500, "paid_cents": 12500, "patient_resp_cents": 0, "contractual_cents": 100}], "carcs": [], "rarcs": [], "posted": false, "transaction": "835"}, "era_text": "835 ERA / EOB   CCN=CCN …[truncated]

#24 post_remittance The corrected second submission has an accepted 277CA and paid 835 with $125.00 payer payment, $0 patient... ＋

Agent reasoning

The corrected second submission has an accepted 277CA and paid 835 with $125.00 payer payment, $0 patient responsibility, and $1.00 contractual adjustment. The remaining required step is to post the ERA and reconcile the account balance.

Args · stage closed_paid · day 76

{}

Result

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