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Trajectory · Claim #78489 · 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 · 24 tool calls

#0 portal_login I need to access the payer portal before verifying coverage and any payer-specific claim requirements. Logging in is... ＋

Agent reasoning

I need to access the payer portal before verifying coverage and any payer-specific claim requirements. Logging in is the first operational step and should trigger the OTP needed to proceed.

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/benefit verification and any downstream claim work. The... ＋

Agent reasoning

I need to complete payer portal access before eligibility/benefit verification and any downstream claim work. The login step already sent the simulated OTP, so I will verify it now to proceed.

Args · stage intake · day 0

{"code": "000000"}

Result

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

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

Agent reasoning

Before coding or billing, I need to verify active coverage for the date of service and identify any COB/benefit details from the 270/271 response. This will determine whether United Healthcare Oxford is billable as primary and whether there is patient responsibility.

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"}

#3 read_chart I need to review the source progress note before coding to confirm the documented injury, laterality, acuity,... ＋

Agent reasoning

I need to review the source progress note before coding to confirm the documented injury, laterality, acuity, orders, and whether the E/M can be leveled by MDM or time. This should identify any ambiguity requiring a provider query before charge capture and diagnosis assignment.

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]

#4 review_documentation I need to complete the required coder documentation review before assigning diagnoses or services. This should... ＋

Agent reasoning

I need to complete the required coder documentation review before assigning diagnoses or services. This should identify whether the ankle injury documentation is sufficient or if a provider query is needed for ambiguity such as diagnosis specificity or laterality.

Args · stage documentation · day 0

{}

Result

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

#5 capture_charges Eligibility and documentation review are complete, and there are no open queries. Next I need to aggregate the... ＋

Agent reasoning

Eligibility and documentation review are complete, and there are no open queries. Next I need to aggregate the encounter’s billable activities from the chart/charge feed before assigning CPT/HCPCS lines, so I will capture charges now.

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_icd10 The documentation supports an acute right ankle twisting injury with swelling/pain, most consistent with a right... ＋

Agent reasoning

The documentation supports an acute right ankle twisting injury with swelling/pain, most consistent with a right ankle sprain; I need to verify the ICD-10-CM code before setting Box 21. I’m choosing an unspecified ligament/right ankle/initial encounter code because the specific ligament is not documented and this is active treatment for the initial visit.

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."}

#7 kb_coding_guidelines Before committing CPT lines, I need confirm how this payer/workflow expects urgent-care visit activity to be... ＋

Agent reasoning

Before committing CPT lines, I need confirm how this payer/workflow expects urgent-care visit activity to be translated, especially whether to bill a standard new-patient E/M or an urgent-care global HCPCS/case-rate. This guideline lookup should clarify service-line construction and any POS/modifier expectations.

Args · stage charge_capture · day 0

{"topic": "service_lines"}

Result

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

#8 kb_lookup_em_guidelines I need to level the new-patient urgent care E/M from the documented MDM rather than defaulting to the lowest level.... ＋

Agent reasoning

I need to level the new-patient urgent care E/M from the documented MDM rather than defaulting to the lowest level. The chart shows one acute ankle injury with no orders or prescription management, so I am checking whether 99203 criteria fit before committing the service line.

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."}

#9 kb_coding_guidelines The encounter is an urgent-care new visit and the prompt warns that UC charge-feed activity may map to a global... ＋

Agent reasoning

The encounter is an urgent-care new visit and the prompt warns that UC charge-feed activity may map to a global case-rate HCPCS rather than a standard E/M. I need the payer/coding rule for urgent-care charge mapping before setting Box 24 so I do not burn a submission with the wrong service code.

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_payer_policy Before committing the service line, I need to confirm whether this Oxford urgent-care claim should be billed as a... ＋

Agent reasoning

Before committing the service line, I need to confirm whether this Oxford urgent-care claim should be billed as a contracted urgent-care global case-rate rather than a separate office E/M. The payer policy should clarify whether S9083 is required/accepted for this plan and POS 20.

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"}}

#11 kb_lookup_cpt The captured charge appears to be an urgent-care visit with no procedures, labs, imaging, or drugs documented.... ＋

Agent reasoning

The captured charge appears to be an urgent-care visit with no procedures, labs, imaging, or drugs documented. Before setting Box 24, I need to verify the urgent-care global/case-rate HCPCS code rather than defaulting to a standard E/M code.

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"]}

#12 set_diagnoses The documented condition is an acute right ankle injury/sprain, laterality is clear, and the diagnosis lookup for... ＋

Agent reasoning

The documented condition is an acute right ankle injury/sprain, laterality is clear, and the diagnosis lookup for S93.401A was already checked. I will now set the ICD-10-CM diagnosis in Box 21 primary-first so the service line can point to it.

Args · stage coding · day 0

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

Result

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

#13 set_service_lines The captured activity is the urgent-care encounter/global service, and there were no ordered labs/imaging,... ＋

Agent reasoning

The captured activity is the urgent-care encounter/global service, and there were no ordered labs/imaging, procedures, injections, or supplies requiring separate lines. For this payer/UC setting, I will bill the all-inclusive urgent care case-rate HCPCS with POS 20 and point it to the ankle sprain 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": ""}]}

#14 run_scrub The claim currently has active eligibility, COB resolved, diagnosis and urgent-care global service line set, with no... ＋

Agent reasoning

The claim currently has active eligibility, COB resolved, diagnosis and urgent-care global service line set, with no ordered labs/imaging or drug/NDC requirements. I will run the pre-submission scrub now to catch any payer, modifier, medical-necessity, POS, NDC, referring, or header issues before using a submission attempt.

Args · stage coding · day 0

{}

Result

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

#15 submit_claim Eligibility, COB, documentation review, charge capture, diagnosis/service-line coding, provider taxonomy, and... ＋

Agent reasoning

Eligibility, COB, documentation review, charge capture, diagnosis/service-line coding, provider taxonomy, and pre-submission scrub are already complete and clean. The current coding has not been submitted before, so I will transmit the initial 837P and obtain payer acknowledgments/remittance outcome.

Args · stage denial · day 23

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-da9d651b44", "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-17cb835c09", "stage": "adjudication", "s …[truncated]

#16 kb_lookup_carc The denial cites CARC CO-16 with RARC M51 for an invalid/missing procedure code, so I need to confirm the payer’s... ＋

Agent reasoning

The denial cites CARC CO-16 with RARC M51 for an invalid/missing procedure code, so I need to confirm the payer’s stated remedy before changing the CPT/HCPCS. This will guide whether the failed S9083 line should be replaced with a documented office/urgent-care E/M code or another supported service code.

Args · stage denial · day 23

{"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"}

#17 portal_download_era The payer denied the initial claim at adjudication for an invalid/unsupported procedure code, and before burning a... ＋

Agent reasoning

The payer denied the initial claim at adjudication for an invalid/unsupported procedure code, and before burning a resubmission I need to review the full ERA/EOB details to confirm the denied line and any payer-specific remark guidance. This should tell me whether only the CPT/HCPCS line must be corrected or whether additional claim elements are implicated.

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-da9d651b44", "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_coding_guidelines The denial specifically says S9083 is unsupported and the documented professional service must be reconciled to the... ＋

Agent reasoning

The denial specifically says S9083 is unsupported and the documented professional service must be reconciled to the chart. I need to re-check the E/M coding rules before replacing the denied urgent-care global code with the correct new-patient office/urgent-care E/M level.

Args · stage denial · day 23

{"topic": "em"}

Result

{"topic": "em", "guidelines": ["Level Evaluation & Management from documented MDM (medical decision making) OR total time on the date of service - not from a term search.", "MDM has three elements (number/complexity of problems, amount/complexity of data reviewed, risk of complications); the level is the 2-of-3 that are met or exceeded.", "Do NOT default to the lowest level. Most urgent-care visits are NOT straightforward (99202/99212): an acute illness/injury that is evaluated, worked up, or tr …[truncated]

#19 kb_lookup_cpt The denial specifically identifies S9083 as an invalid/unsupported procedure code for the documented encounter. I am... ＋

Agent reasoning

The denial specifically identifies S9083 as an invalid/unsupported procedure code for the documented encounter. I am verifying the replacement new-patient E/M CPT I derived from the chart before updating the denied line.

Args · stage denial · day 23

{"code": "99203"}

Result

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

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

Agent reasoning

The denial specifically identifies S9083 as an invalid/unsupported procedure code for the documented service. The chart supports a new-patient urgent-care office/outpatient E/M visit with low MDM for an acute uncomplicated right ankle sprain, so I am replacing the denied UC case-rate code with 99203 and keeping POS 20 and dx pointer 1.

Args · stage coding · day 23

{"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": ""}]}

#21 run_scrub The denied S9083 line has been replaced with the documented new-patient urgent-care E/M line 99203. Before using... ＋

Agent reasoning

The denied S9083 line has been replaced with the documented new-patient urgent-care E/M line 99203. Before using another submission attempt, I need to run the payer/claim scrub on the corrected coding to catch any remaining NCCI, medical-necessity, POS, modifier, or header issues.

Args · stage coding · day 23

{}

Result

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

#22 submit_claim The denied coding used S9083, but the current corrected line is 99203 for the documented new-patient urgent-care... ＋

Agent reasoning

The denied coding used S9083, but the current corrected line is 99203 for the documented new-patient urgent-care E/M, linked to S93.401A, and the scrub is clean. Since the corrected coding differs from the failed submission and no ordered services/drugs/auth are present, the next step is to resubmit the corrected 837P.

Args · stage remittance · day 46

{}

Result

{"ok": true, "result": "835_paid", "remit": {"remit_id": "era-8834b51bff", "status": "paid", "billed_cents": 15100, "allowed_cents": 15000, "paid_cents": 13000, "patient_resp_cents": 0, "contractual_cents": 0, "claim_control_number": "CCN78489-2", "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]

#23 post_remittance The corrected second submission has a paid 835 with patient responsibility $0, and the only remaining checklist item... ＋

Agent reasoning

The corrected second submission has a paid 835 with patient responsibility $0, and the only remaining checklist item is to post the remittance. I will post the ERA payment and reconcile the zero patient balance to close the revenue-cycle work.

Args · stage closed_paid · day 46

{}

Result

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