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Trajectory · Claim #78489 · trial 1

GPT-5.5 openai

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

Reward

0.60

Coding

100%

Tool calls

Final stage

closed_paid

Tool-by-tool trajectory · 41 tool calls

#0 check_eligibility I need to verify active coverage for the DOS before coding or submitting, including any COB information that may... ＋

Agent reasoning

I need to verify active coverage for the DOS before coding or submitting, including any COB information that may affect the primary payer. I will run the 270/271 eligibility check for this United Healthcare Oxford plan.

Args · stage eligibility · day 0

{}

Result

{"ok": true, "coverages": [{"rank": "primary", "payer": "UNITED HEALTHCARE OXFORD FREEDOM NETWORK", "member_id": "M1BEF2C8CD", "group": "GRP-0C50", "status": "active", "copay_cents": 2500, "deductible_remaining_cents": 0}], "cob_required": false, "note": "active coverage verified"}

#1 read_chart I need to independently review the encounter documentation before assigning diagnoses or CPT levels, especially the... ＋

Agent reasoning

I need to independently review the encounter documentation before assigning diagnoses or CPT levels, especially the injury details, exam, plan, and any embedded billing/order information. I will open the progress note first to confirm the clinical facts and whether any procedures, supplies, imaging, or medications were documented.

Args · stage eligibility · day 0

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 14:50:00  |  End Time: 15:05:00  |  Length of Stay: 15 min  |  Reason: pain, ankle  |  Visit type: UC - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHistory: pt twisted right ankle approx 1 week ago.  still in pain\n[EXTREMITIES:] Right ankle swelling noted at lateral malleolus; full rom with pain at lateral malleolus on inversion.\n[SKIN:] warm and dry, no suspicious lesions\n[NEUROL …[truncated]

#2 review_documentation I need to complete the formal coder documentation review before assigning ICD-10/CPT, and this will identify whether... ＋

Agent reasoning

I need to complete the formal coder documentation review before assigning ICD-10/CPT, and this will identify whether the ankle diagnosis/laterality or E/M support is ambiguous enough to require a provider query.

Args · stage documentation · day 0

{}

Result

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

#3 capture_charges I need to aggregate the billable activities from the chart/charge feed before choosing CPT/HCPCS lines, since there... ＋

Agent reasoning

I need to aggregate the billable activities from the chart/charge feed before choosing CPT/HCPCS lines, since there may be an urgent-care global charge or missed supplies not obvious from the note. This will tell me what clinical activities must be mapped to codes.

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]

#4 kb_lookup_icd10 The note documents a right ankle twist with lateral malleolar swelling/pain, consistent with an initial encounter... ＋

Agent reasoning

The note documents a right ankle twist with lateral malleolar swelling/pain, consistent with an initial encounter for right ankle sprain; before setting Box 21 I need to verify the specific ICD-10-CM code description.

Args · stage charge_capture · day 0

{"code": "S93.401A"}

Result

{"code": "S93.401A", "found": true, "description": "Sprain of unspecified ligament of right ankle, initial encounter", "note": "Description only - confirm this is the specific code the documentation supports before committing it."}

#5 kb_lookup_payer_policy I need the payer/companion-guide rules before selecting the service line, especially because urgent-care encounters... ＋

Agent reasoning

I need the payer/companion-guide rules before selecting the service line, especially because urgent-care encounters may require a global urgent-care HCPCS instead of standard E/M billing. This should confirm whether UHC Oxford Freedom expects an urgent-care case-rate line and any header/provider requirements before I commit codes.

Args · stage charge_capture · day 0

{}

Result

{"payer": "UNITED HEALTHCARE OXFORD FREEDOM NETWORK", "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": 267, "appeal_levels": ["first_level_appeal", "second_level_appeal", "external_review"], "denial_timing_days": 21, "auth_required_services": ["70551", "70553", "72148", "73721", "20610"], "payer_id": "95227"}}

#6 kb_coding_guidelines I need to determine whether the captured urgent-care activity should be billed as an urgent-care global case-rate... ＋

Agent reasoning

I need to determine whether the captured urgent-care activity should be billed as an urgent-care global case-rate HCPCS rather than a standard office/outpatient E/M, so I am checking the service-line coding rules before setting 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]

#7 kb_lookup_cpt The documented visit is a new urgent-care evaluation for one acute uncomplicated ankle injury with no... ＋

Agent reasoning

The documented visit is a new urgent-care evaluation for one acute uncomplicated ankle injury with no orders/procedures/drugs, so I need to verify the likely new-patient E/M code descriptor before setting the service line.

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"}

#8 kb_lookup_cpt The captured urgent-care activity may need to be billed as the urgent care global case-rate rather than a standard... ＋

Agent reasoning

The captured urgent-care activity may need to be billed as the urgent care global case-rate rather than a standard new-patient E/M. I am verifying HCPCS S9083 before setting the service line so the first submission does not waste a claim attempt.

Args · stage charge_capture · 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"]}

#9 kb_lookup_icd10 Before committing Box 21, I want to verify whether a more specific right ankle sprain code is available for the... ＋

Agent reasoning

Before committing Box 21, I want to verify whether a more specific right ankle sprain code is available for the documented lateral/inversion injury, rather than using an unspecified ligament code without confirmation. This lookup will confirm the official ICD-10-CM description for the candidate code.

Args · stage charge_capture · day 0

{"code": "S93.491A"}

Result

{"code": "S93.491A", "found": false, "note": "Description only - confirm this is the specific code the documentation supports before committing it."}

#10 set_diagnoses The chart supports a right ankle sprain without a documented specific ligament; before building service lines, I... ＋

Agent reasoning

The chart supports a right ankle sprain without a documented specific ligament; before building service lines, I need to set the ICD-10-CM diagnosis in Box 21 using the previously verified code and sequence it as primary/only diagnosis.

Args · stage coding · day 0

{"codes": ["S93.401A"]}

Result

{"ok": true, "diagnoses": [{"sequence": 1, "code": "S93.401A"}]}

#11 kb_coding_guidelines Before committing the professional line, I need confirm whether this payer/urgent-care setting expects the captured... ＋

Agent reasoning

Before committing the professional line, I need confirm whether this payer/urgent-care setting expects the captured urgent-care activity to be billed as a global case-rate HCPCS rather than a standard new-patient E/M, so the first submission does not waste a try.

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]

#12 portal_login Eligibility is already confirmed and coding is mostly staged, but the workflow still requires payer portal access... ＋

Agent reasoning

Eligibility is already confirmed and coding is mostly staged, but the workflow still requires payer portal access before submission/remittance handling. I am logging in now so I can complete portal-dependent steps if the claim needs ERA, denial, or authorization verification later.

Args · stage coding · day 0

{}

Result

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

#13 portal_verify_otp I need to complete payer portal login before any portal-dependent follow-up such as ERA retrieval or payer status... ＋

Agent reasoning

I need to complete payer portal login before any portal-dependent follow-up such as ERA retrieval or payer status work. The OTP was just issued by the simulator, so I will verify it now.

Args · stage coding · day 0

{"code": "000000"}

Result

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

#14 set_service_lines The captured urgent-care activity should be billed as the payer-recognized urgent care global/case-rate HCPCS rather... ＋

Agent reasoning

The captured urgent-care activity should be billed as the payer-recognized urgent care global/case-rate HCPCS rather than a separate office E/M. I will set one POS 20 service line linked to the ankle-sprain diagnosis with no modifier or NDC/referring requirement.

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, charge capture, diagnosis, provider identity, and urgent-care global service... ＋

Agent reasoning

Eligibility, COB, documentation review, charge capture, diagnosis, provider identity, and urgent-care global service line are already set. I am running the pre-submission scrub now to catch any payer, coding, modifier, medical-necessity, NDC, prior-auth, or referring-provider issues before using a submission attempt.

Args · stage coding · day 0

{}

Result

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

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

Agent reasoning

Eligibility/COB, provider identity, diagnosis, urgent-care global service line, and scrub are already complete and clean. No ordered labs/imaging, drugs, or prior authorization are documented, so the next appropriate step is to transmit the first 837P submission and obtain payer acknowledgments/remittance.

Args · stage denial · day 23

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-b19c954bcc", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN78489-1", "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-2775bb3e34", "stage": "adjudication", "s …[truncated]

#17 portal_download_era The claim denied for CO-16/M51 on the S9083 procedure line, so I need to review the payer’s full ERA detail before... ＋

Agent reasoning

The claim denied for CO-16/M51 on the S9083 procedure line, so I need to review the payer’s full ERA detail before changing the coding. I expect this to confirm whether the denial is limited to the urgent-care global HCPCS and whether any other claim elements were rejected.

Args · stage denial · day 23

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN78489-1\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-b19c954bcc", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN78489-1", "line …[truncated]

#18 kb_lookup_payer_policy The denial specifically says the submitted S9083 procedure code is invalid for the documented service, so I need to... ＋

Agent reasoning

The denial specifically says the submitted S9083 procedure code is invalid for the documented service, so I need to verify the payer’s coding policy before replacing it. I expect the payer policy to clarify whether this Oxford plan requires standard office/outpatient E/M codes instead of an urgent-care global code.

Args · stage denial · day 23

{}

Result

{"payer": "UNITED HEALTHCARE OXFORD FREEDOM NETWORK", "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": 267, "appeal_levels": ["first_level_appeal", "second_level_appeal", "external_review"], "denial_timing_days": 21, "auth_required_services": ["70551", "70553", "72148", "73721", "20610"], "payer_id": "95227"}}

#19 kb_lookup_cpt The denial indicates S9083 is not supported for this encounter, so I am re-deriving the visit as a standard... ＋

Agent reasoning

The denial indicates S9083 is not supported for this encounter, so I am re-deriving the visit as a standard new-patient E/M based on the documented urgent-care evaluation with no separately billable procedures, labs, imaging, drugs, or supplies. I need to verify CPT 99202 before replacing the denied S9083 line.

Args · stage denial · day 23

{"code": "99202"}

Result

{"code": "99202", "found": true, "desc": "Office/outpatient E/M, NEW patient, straightforward MDM", "category": "em_new", "patient": "new", "mdm": "straightforward"}

#20 set_service_lines The denial specifically rejected S9083 as an invalid/unsupported procedure code for the documented service. The... ＋

Agent reasoning

The denial specifically rejected S9083 as an invalid/unsupported procedure code for the documented service. The chart supports a new-patient urgent-care E/M only, with one uncomplicated right ankle injury, no orders/procedures/drugs, so I am replacing the denied global UC code with verified CPT 99202 before scrubbing/resubmission.

Args · stage coding · day 23

{"lines": [{"cpt": "99202", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20"}]}

Result

{"ok": true, "service_lines": [{"cpt": "99202", "modifiers": [], "units": 1, "dx_pointers": [1], "place_of_service": "20", "ndc": ""}]}

#21 run_scrub The denied S9083 line has been corrected to a documented new-patient E/M 99202, so before using a remaining... ＋

Agent reasoning

The denied S9083 line has been corrected to a documented new-patient E/M 99202, so before using a remaining submission I need to re-run the payer scrub on the updated claim to confirm CPT, POS, dx pointer, and header requirements are clean.

Args · stage coding · day 23

{}

Result

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

#22 kb_lookup_payer_policy The denial says the submitted urgent-care global code was invalid/unsubstantiated, and the current corrected line is... ＋

Agent reasoning

The denial says the submitted urgent-care global code was invalid/unsubstantiated, and the current corrected line is an office/urgent-care E/M. Before burning a resubmission, I need to confirm the payer’s Oxford professional-claim policy for urgent care POS 20 and whether S9083 or standard E/M is expected for this contract.

Args · stage denial · day 46

{}

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"}

#23 submit_claim The corrected claim has already been updated to CPT 99202, scrubbed clean, and differs from the denied S9083... ＋

Agent reasoning

The corrected claim has already been updated to CPT 99202, scrubbed clean, and differs from the denied S9083 submission. Since the payer denial required correction and resubmission, I will transmit the clean corrected 837P now to obtain the payer response.

Args · stage denial · day 46

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-30f75fc0d4", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN78489-2", "lines": [{"cpt": "99202", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-150", "rarcs": ["M25"]}], "carcs": ["CO-150"], "rarcs": ["M25"], "posted": false, "transaction": "835"}, "denial": {"denial_id": "den-a09cfb9919", "stage": "adjudication",  …[truncated]

#24 kb_lookup_carc The payer denied the 99202 line as unsupported E/M level and noted possible missed services. I’m looking up CARC... ＋

Agent reasoning

The payer denied the 99202 line as unsupported E/M level and noted possible missed services. I’m looking up CARC CO-150 to confirm the denial meaning and recommended correction path before using the final submission attempt.

Args · stage denial · day 46

{"carc": "CO-150"}

Result

{"code": "CO-150", "found": false, "rarcs": [], "note": "CO-150 not in KB; refer to CMS CARC manual"}

#25 portal_download_era The current claim is in adjudication denial status and we have only one remaining submission, so I need to read the... ＋

Agent reasoning

The current claim is in adjudication denial status and we have only one remaining submission, so I need to read the full ERA/EOB before changing coding. This should confirm the exact denied line, payer rationale, allowed amounts, and whether the payer indicates a different expected service such as the urgent-care global code or a lower E/M level.

Args · stage denial · day 46

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN78489-2\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-150\n  RARC: M25\n    99202: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-150 M25]", "era": {"remit_id": "era-30f75fc0d4", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN78489-2", "li …[truncated]

#26 kb_lookup_payer_policy The denial specifically says the billed E/M level is unsupported and that services may be unbilled, and we have only... ＋

Agent reasoning

The denial specifically says the billed E/M level is unsupported and that services may be unbilled, and we have only one remaining submission. I need to confirm this payer’s urgent-care billing requirements before choosing whether the corrected claim should be E/M-based or a payer-specific urgent-care/global code with required claim elements.

Args · stage denial · day 46

{}

Result

{"payer": "UNITED HEALTHCARE OXFORD FREEDOM NETWORK", "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": 267, "appeal_levels": ["first_level_appeal", "second_level_appeal", "external_review"], "denial_timing_days": 21, "auth_required_services": ["70551", "70553", "72148", "73721", "20610"], "payer_id": "95227"}}

#27 read_chart The denial specifically says the billed E/M level and captured services do not reconcile to the chart, and we have... ＋

Agent reasoning

The denial specifically says the billed E/M level and captured services do not reconcile to the chart, and we have only one submission left. I need to re-open the encounter documentation now to verify whether the visit is actually a global urgent-care service, a lower/non-billable E/M, or has a separately billable screening/form before changing the claim.

Args · stage denial · day 46

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 14:50:00  |  End Time: 15:05:00  |  Length of Stay: 15 min  |  Reason: pain, ankle  |  Visit type: UC - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nHistory: pt twisted right ankle approx 1 week ago.  still in pain\n[EXTREMITIES:] Right ankle swelling noted at lateral malleolus; full rom with pain at lateral malleolus on inversion.\n[SKIN:] warm and dry, no suspicious lesions\n[NEUROL …[truncated]

#28 kb_lookup_cpt The denial specifically says the UC encounter appears to have an unbilled service in addition to the E/M. I’m... ＋

Agent reasoning

The denial specifically says the UC encounter appears to have an unbilled service in addition to the E/M. I’m checking the urgent-care add-on HCPCS code before changing the final submission, so I can verify the exact code description and avoid burning the last claim attempt with an unsupported line.

Args · stage denial · day 46

{"code": "S9088"}

Result

{"code": "S9088", "found": false, "note": "not in encoder; verify against CPT/HCPCS manual"}

#29 kb_coding_guidelines The denial specifically says the submitted E/M is unsupported and that a documented service may be unbilled, so I... ＋

Agent reasoning

The denial specifically says the submitted E/M is unsupported and that a documented service may be unbilled, so I need to confirm payer/claim-line coding rules for urgent-care charge types before using the final submission. I am checking service-line guidance to determine whether the urgent care encounter should be billed as an E/M, an urgent-care global/case-rate HCPCS, or another line combination.

Args · stage denial · day 46

{"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]

#30 capture_charges The denial specifically says the E/M line is unsupported and that documented services may be unbilled, so before... ＋

Agent reasoning

The denial specifically says the E/M line is unsupported and that documented services may be unbilled, so before using the final submission I need to re-reconcile the encounter charge capture against the chart rather than guess a new E/M level. This should reveal whether the urgent-care visit activity includes a non-E/M facility/urgent-care add-on or other billable item that must be billed with the professional service.

Args · stage denial · day 46

{}

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]

#31 kb_lookup_carc The payer denied the current 99202 line as unsupported, so I need to confirm the official CARC CO-150 meaning and... ＋

Agent reasoning

The payer denied the current 99202 line as unsupported, so I need to confirm the official CARC CO-150 meaning and recommended remedy before using the final submission attempt. This will guide whether to correct the E/M/service-line coding or prepare an appeal path.

Args · stage denial · day 46

{"carc": "CO-150"}

Result

{"code": "CO-150", "found": false, "rarcs": [], "note": "CO-150 not in KB; refer to CMS CARC manual"}

#32 capture_charges The denial specifically says an unbilled documented service may be missing, so I need to re-open the charge capture... ＋

Agent reasoning

The denial specifically says an unbilled documented service may be missing, so I need to re-open the charge capture output and reconcile the chart activity before burning the final submission attempt. I expect this to identify whether the urgent-care facility/service component or another billable activity must be added to the E/M line.

Args · stage denial · day 46

{}

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]

#33 portal_download_era The claim is in adjudication denial after the second submission, and we need the full ERA/EOB detail before using... ＋

Agent reasoning

The claim is in adjudication denial after the second submission, and we need the full ERA/EOB detail before using the final submission attempt. I will download the ERA to confirm the exact denial basis, line-level adjudication, and any payer-specific remark that may affect the corrected coding.

Args · stage denial · day 46

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN78489-2\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-150\n  RARC: M25\n    99202: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-150 M25]", "era": {"remit_id": "era-30f75fc0d4", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN78489-2", "li …[truncated]

#34 kb_lookup_payer_policy The 99202 denial indicates the payer may expect a different urgent-care billing methodology or a missing urgent-care... ＋

Agent reasoning

The 99202 denial indicates the payer may expect a different urgent-care billing methodology or a missing urgent-care service line. Before using the final submission attempt, I need to confirm Oxford’s companion-guide rules for urgent care case-rate versus E/M billing and any taxonomy/header requirements.

Args · stage denial · day 46

{}

Result

{"payer": "UNITED HEALTHCARE OXFORD FREEDOM NETWORK", "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": 267, "appeal_levels": ["first_level_appeal", "second_level_appeal", "external_review"], "denial_timing_days": 21, "auth_required_services": ["70551", "70553", "72148", "73721", "20610"], "payer_id": "95227"}}

#35 kb_lookup_em_guidelines The denial is specifically about E/M level support, and the chart describes a new-patient urgent-care visit for an... ＋

Agent reasoning

The denial is specifically about E/M level support, and the chart describes a new-patient urgent-care visit for an acute ankle injury that may support low MDM rather than the previously billed straightforward 99202. I need to verify the formal 99203 E/M criteria before changing the last remaining resubmission.

Args · stage denial · day 46

{"level": "99203"}

Result

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

#36 kb_lookup_cpt The denial is specific to the E/M level, and based on the chart this new urgent-care visit for an acute... ＋

Agent reasoning

The denial is specific to the E/M level, and based on the chart this new urgent-care visit for an acute uncomplicated right ankle injury appears to support low MDM rather than the previously billed 99202. Before changing the line, I need to verify the CPT descriptor for 99203 so the corrected claim will differ from both prior submissions and match the documented MDM.

Args · stage coding · day 46

{"code": "99203"}

Result

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

#37 set_service_lines The denial is on the E/M line and the documented presentation is a new urgent-care visit for an acute uncomplicated... ＋

Agent reasoning

The denial is on the E/M line and the documented presentation is a new urgent-care visit for an acute uncomplicated ankle injury with a medically appropriate exam, which supports low MDM rather than straightforward MDM. I will correct the E/M from the previously denied 99202 to 99203 while keeping the established diagnosis pointer and POS before re-scrubbing.

Args · stage coding · day 46

{"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": ""}]}

#38 run_scrub Before using the last remaining submission, I need to confirm whether the currently revised 99203 line passes payer... ＋

Agent reasoning

Before using the last remaining submission, I need to confirm whether the currently revised 99203 line passes payer and coding edits after the E/M correction and no required header elements are missing. A clean scrub will validate NCCI, medical necessity, modifiers, POS, and required fields before resubmission.

Args · stage remittance · day 69

{}

Result

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

#39 submit_claim The claim has been corrected to a different E/M level than the prior denied 99202, the diagnosis and POS are set,... ＋

Agent reasoning

The claim has been corrected to a different E/M level than the prior denied 99202, the diagnosis and POS are set, provider identity is correct, and the pre-submission scrub is clean. With only one submission remaining, the corrected 99203 line is the supported low-MDM new patient E/M for an acute uncomplicated ankle injury, so I am submitting the corrected 837P now.

Args · stage closed_paid · day 69

{}

Result

{"ok": true, "result": "835_paid", "remit": {"remit_id": "era-1696a9288d", "status": "paid", "billed_cents": 15100, "allowed_cents": 15000, "paid_cents": 13000, "patient_resp_cents": 0, "contractual_cents": 0, "claim_control_number": "CCN78489-3", "lines": [{"cpt": "99203", "billed_cents": 15100, "allowed_cents": 15000, "paid_cents": 13000, "patient_resp_cents": 0, "contractual_cents": 0}], "carcs": [], "rarcs": [], "posted": false, "transaction": "835"}, "era_text": "835 ERA / EOB   CCN=CCN7848 …[truncated]

#40 post_remittance The third submission has returned a paid 835 with $0 patient responsibility, and the checklist shows the only... ＋

Agent reasoning

The third submission has returned a paid 835 with $0 patient responsibility, and the checklist shows the only remaining required step is to post the remittance. I will post the ERA payment and reconcile the account balance.

Args · stage None · day None

{}

Result

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