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Trajectory · Claim #78489 · trial 3

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 · 43 tool calls

#0 portal_login I need to access the payer portal before verifying eligibility and any payer-specific claim requirements. This... ＋

Agent reasoning

I need to access the payer portal before verifying eligibility and any payer-specific claim requirements. This should initiate login and OTP so I can proceed with member coverage verification.

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 login before verifying eligibility and checking payer-specific requirements. The OTP... ＋

Agent reasoning

I need to complete payer portal login before verifying eligibility and checking payer-specific requirements. The OTP was already sent, so I will verify it using the simulated code provided.

Args · stage intake · day 0

{"code": "000000"}

Result

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

#2 check_eligibility Coverage must be verified via 270/271 before billing or coding submission. I will run eligibility for the listed... ＋

Agent reasoning

Coverage must be verified via 270/271 before billing or coding submission. I will run eligibility for the listed United Healthcare Oxford Freedom Network policy to confirm active coverage, benefits, and any COB indicators.

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 clinical documentation in detail before assigning ICD-10-CM and CPT/E/M level, especially... ＋

Agent reasoning

I need to review the clinical documentation in detail before assigning ICD-10-CM and CPT/E/M level, especially because the only diagnosis is SNOMED-coded and there are no charge codes in the feed. I will start by opening the progress note to confirm the documented ankle condition, laterality, acuity, services performed, and whether any orders/procedures/medications are present.

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 Eligibility is already confirmed, so the next required step is a coder documentation review to identify any... ＋

Agent reasoning

Eligibility is already confirmed, so the next required step is a coder documentation review to identify any ambiguity, missing elements, or billable services before assigning ICD-10/CPT codes.

Args · stage documentation · day 0

{}

Result

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

#5 capture_charges The documentation review is complete and no provider query is needed. Next I need to aggregate all billable... ＋

Agent reasoning

The documentation review is complete and no provider query is needed. Next I need to aggregate all billable professional charges from the encounter before assigning CPT/HCPCS service lines, so I will run charge capture 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 documented SNOMED diagnosis and exam support a right ankle sprain after a twisting injury, but I need to verify... ＋

Agent reasoning

The documented SNOMED diagnosis and exam support a right ankle sprain after a twisting injury, but I need to verify the exact ICD-10-CM code before setting Box 21. I will confirm the official description for unspecified sprain of the right ankle, initial encounter.

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 Box 24, I need the payer/workflow rule for this urgent-care charge-feed activity, specifically... ＋

Agent reasoning

Before committing Box 24, I need the payer/workflow rule for this urgent-care charge-feed activity, specifically whether this visit is billed as a standard office/outpatient E/M or an urgent-care global/case-rate HCPCS. This will prevent wasting a submission on 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]

#8 kb_lookup_em_guidelines There are no separately documented procedures, drugs, labs, or imaging, so the claim appears to hinge on the correct... ＋

Agent reasoning

There are no separately documented procedures, drugs, labs, or imaging, so the claim appears to hinge on the correct new-patient urgent-care E/M level. I’m checking the 99203 E/M criteria because the documented right ankle injury is an acute uncomplicated injury with low-complexity MDM, and time is not clearly documented as physician/QHP total time.

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_lookup_cpt The captured activity appears to be an urgent-care visit with no separate procedures, labs, imaging, or drugs. I... ＋

Agent reasoning

The captured activity appears to be an urgent-care visit with no separate procedures, labs, imaging, or drugs. I need to verify the urgent care global HCPCS code before setting the service line so I do not incorrectly bill a standard E/M if the payer expects the UC case-rate 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"]}

#10 set_diagnoses The chart documents a right ankle twist with lateral malleolar swelling and pain, and the SNOMED primary diagnosis... ＋

Agent reasoning

The chart documents a right ankle twist with lateral malleolar swelling and pain, and the SNOMED primary diagnosis corresponds clinically to an ankle sprain. I will set the ICD-10-CM diagnosis to the specific right-ankle initial-encounter sprain code, without adding separate ankle pain because it is integral to the sprain diagnosis.

Args · stage coding · day 0

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

Result

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

#11 kb_lookup_payer_policy Before committing the single urgent-care service line, I need to confirm this payer’s professional claim... ＋

Agent reasoning

Before committing the single urgent-care service line, I need to confirm this payer’s professional claim requirements, including whether Oxford Freedom Network expects the urgent-care case-rate HCPCS versus a standard E/M and any header/taxonomy requirements.

Args · stage coding · 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"}}

#12 set_service_lines The chart supports only one billable urgent-care encounter for a new patient with no separately ordered labs,... ＋

Agent reasoning

The chart supports only one billable urgent-care encounter for a new patient with no separately ordered labs, imaging, procedures, or drugs. Because the captured activity is an urgent-care global service for this commercial payer, I will bill the UC global case-rate HCPCS rather than a separate E/M code.

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": ""}]}

#13 run_scrub Eligibility, COB, documentation review, diagnosis, urgent-care global service line, provider taxonomy, and absence... ＋

Agent reasoning

Eligibility, COB, documentation review, diagnosis, urgent-care global service line, provider taxonomy, and absence of orders/auth needs are already addressed. I’m running the pre-submission scrub now to catch any payer/NCCI/modifier/referring/auth/NDC issues before using a submission attempt.

Args · stage coding · day 0

{}

Result

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

#14 submit_claim Eligibility, COB, provider identity, diagnosis, UC global service line, and scrub are already complete and clean.... ＋

Agent reasoning

Eligibility, COB, provider identity, diagnosis, UC global service line, and scrub are already complete and clean. This is the first submission and the current coding has not been tried before, so I will transmit the 837P and review payer acknowledgments/remit outcome.

Args · stage denial · day 23

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-5f13ce08c7", "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-f760bc0640", "stage": "adjudication", "s …[truncated]

#15 kb_lookup_carc The payer denied the submitted S9083 line with CO-16/M51, indicating a missing or invalid procedure-code issue. I’m... ＋

Agent reasoning

The payer denied the submitted S9083 line with CO-16/M51, indicating a missing or invalid procedure-code issue. I’m looking up the denial code first so I can confirm the required correction pathway before changing the service line and using another submission attempt.

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"}

#16 portal_download_era The claim denied at adjudication for an invalid/unsupported procedure code, and before spending another submission I... ＋

Agent reasoning

The claim denied at adjudication for an invalid/unsupported procedure code, and before spending another submission I need to review the full ERA/EOB details to confirm the denied line, payer remarks, and whether any additional remittance-level edits apply beyond the summarized CO-16/M51.

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-5f13ce08c7", "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]

#17 kb_lookup_em_guidelines The denial states S9083 is not a valid/documented procedure code for this encounter, so I need to re-level the... ＋

Agent reasoning

The denial states S9083 is not a valid/documented procedure code for this encounter, so I need to re-level the documented new urgent-care visit as a standard office/outpatient E/M before using a remaining submission. I’m checking the 99202 guideline because the chart shows one acute uncomplicated ankle injury, no ordered data, and minimal documented risk/time support.

Args · stage denial · day 23

{"level": "99202"}

Result

{"code": "99202", "patient": "new", "mdm": "straightforward", "summary": "1 self-limited problem; minimal/none data; minimal risk."}

#18 kb_lookup_em_guidelines The denial specifically rejected S9083, so I need to replace it with the correct professional E/M code. I am... ＋

Agent reasoning

The denial specifically rejected S9083, so I need to replace it with the correct professional E/M code. I am checking 99203 because the documented right ankle injury with swelling/pain appears to be an acute uncomplicated injury, which may support low MDM for a new patient rather than the previously considered straightforward level.

Args · stage denial · day 23

{"level": "99203"}

Result

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

#19 kb_lookup_cpt The denial states S9083 is invalid/unsupported for the documented encounter, so I need to replace it with the... ＋

Agent reasoning

The denial states S9083 is invalid/unsupported for the documented encounter, so I need to replace it with the appropriate new-patient office/urgent-care E/M code. The chart supports a new patient evaluation for an uncomplicated right ankle injury with no separately billable orders/procedures, so I am verifying CPT 99202 before updating the service 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 payer denied the UC global code S9083 as invalid/unsupported for the documented service, so I need to replace it... ＋

Agent reasoning

The payer denied the UC global code S9083 as invalid/unsupported for the documented service, so I need to replace it with the correct fee-for-service E/M derived from the chart. Documentation supports a new-patient urgent care office/outpatient E/M with straightforward MDM and no separately billable orders/procedures/drugs, so I will update Box 24 to 99202 instead of resubmitting the failed S9083 line.

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 replaced with the chart-supported new-patient urgent-care E/M 99202, so I need to run... ＋

Agent reasoning

The denied S9083 line has been replaced with the chart-supported new-patient urgent-care E/M 99202, so I need to run a fresh pre-submission scrub before using another limited payer submission. I expect this to confirm NCCI, modifier, POS, diagnosis linkage, authorization, and header requirements are clean for the corrected claim.

Args · stage coding · day 23

{}

Result

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

#22 submit_claim The denied submission used S9083, but the corrected claim now has a chart-supported new-patient E/M 99202 for the... ＋

Agent reasoning

The denied submission used S9083, but the corrected claim now has a chart-supported new-patient E/M 99202 for the urgent-care visit, with ICD-10 S93.401A, correct POS 20, clean scrub, no auth/referring/NDC requirements, and it differs from the failed coding. I will submit the corrected 837P now to obtain payer intake and adjudication.

Args · stage denial · day 46

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-bd87ba050f", "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-25e2720ebe", "stage": "adjudication",  …[truncated]

#23 kb_lookup_carc The denial is CARC CO-150 with RARC M25, so I need to confirm the payer’s denial meaning/remedy before using the... ＋

Agent reasoning

The denial is CARC CO-150 with RARC M25, so I need to confirm the payer’s denial meaning/remedy before using the last submission attempt. This should clarify whether the correction should be E/M level, missing charge capture, documentation support, or appeal documentation.

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"}

#24 portal_download_era The second submission denied for E/M level/support and possible missed charges; before using the final submission... ＋

Agent reasoning

The second submission denied for E/M level/support and possible missed charges; before using the final submission attempt, I need the full ERA/EOB detail to confirm the exact payer rationale and any line-level/payment-policy clues beyond the summary denial text.

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-bd87ba050f", "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]

#25 kb_coding_guidelines The denial specifically says the E/M level is unsupported and that documented services may be unbilled, so I need to... ＋

Agent reasoning

The denial specifically says the E/M level is unsupported and that documented services may be unbilled, so I need to verify urgent-care-specific billing rules before changing the last remaining submission. I am checking whether this payer/workflow expects an urgent care add-on/global code versus a standard office E/M for POS 20.

Args · stage denial · day 46

{"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]

#26 kb_lookup_em_guidelines The denial says 99202 is not supported and suggests the documented visit level/charges need reconciliation. I need... ＋

Agent reasoning

The denial says 99202 is not supported and suggests the documented visit level/charges need reconciliation. I need to verify the E/M requirements for the likely corrected new-patient level before using the last submission attempt.

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."}

#27 capture_charges The denial points to an E/M level/charge reconciliation issue, and we have only one submission left, so I need to... ＋

Agent reasoning

The denial points to an E/M level/charge reconciliation issue, and we have only one submission left, so I need to verify the exact charge activity currently captured from the chart before changing the claim. This should reveal whether the encounter should be billed as a fee-for-service office E/M or an urgent-care global/case-rate service and whether anything documented was missed.

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]

#28 kb_lookup_cpt The denial says the submitted new-patient E/M level 99202 was not supported, and the latest charge capture feed... ＋

Agent reasoning

The denial says the submitted new-patient E/M level 99202 was not supported, and the latest charge capture feed specifically describes an established-patient E/M activity despite the registration conflict. I will verify the established-patient low-level E/M CPT before changing the line to a coding that differs from both prior submissions and better matches the documented limited ankle evaluation.

Args · stage denial · day 46

{"code": "99212"}

Result

{"code": "99212", "found": true, "desc": "Office/outpatient E/M, ESTABLISHED patient, straightforward MDM", "category": "em_established", "patient": "established", "mdm": "straightforward"}

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

Agent reasoning

The denial specifically says the E/M level is unsupported and that documented services may be unbilled, so before using the last submission I need to inspect the actual charge-capture output again for any non-E/M urgent-care activity or missed billable items that should drive the corrected line selection.

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]

#30 kb_lookup_cpt The denied 99202 appears under-leveled for a new-patient urgent-care E/M involving an acute uncomplicated ankle... ＋

Agent reasoning

The denied 99202 appears under-leveled for a new-patient urgent-care E/M involving an acute uncomplicated ankle injury; before changing the last available resubmission, I need to verify the CPT description for the likely corrected new-patient E/M code 99203.

Args · stage denial · 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"}

#31 portal_download_era The second submission denied for E/M level support and potentially missed services, and before using the final... ＋

Agent reasoning

The second submission denied for E/M level support and potentially missed services, and before using the final submission I need to read the full ERA/EOB details to confirm the exact denial rationale and line-level issue.

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-bd87ba050f", "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]

#32 kb_lookup_payer_policy The denial references both E/M support and an apparently unbilled service, and this payer may have... ＋

Agent reasoning

The denial references both E/M support and an apparently unbilled service, and this payer may have urgent-care-specific billing rules such as S9088 or S9083. Before using the final submission attempt, I need the payer companion policy to determine whether Oxford requires or allows an urgent care add-on/global code with the E/M.

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"}}

#33 kb_lookup_carc The denial is CO-150 with RARC M25, so I need to confirm the payer-standard meaning and recommended remedy before... ＋

Agent reasoning

The denial is CO-150 with RARC M25, so I need to confirm the payer-standard meaning and recommended remedy before using the final submission attempt. This should help determine whether the issue is E/M level support, missing charge capture, or documentation attachment/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"}

#34 read_chart The denial specifically says the submitted E/M level is unsupported and that documented services may be unbilled. I... ＋

Agent reasoning

The denial specifically says the submitted E/M level is unsupported and that documented services may be unbilled. I need to inspect the attached Tobacco Control form to determine whether there is separately billable tobacco screening/counseling or other documented activity that should change the service lines before using the final submission attempt.

Args · stage denial · day 46

{"section": "documents"}

Result

{"section": "documents", "body": "(no such section)"}

#35 kb_lookup_em_guidelines The denial is specifically that the billed new-patient E/M level was not supported, so I need to re-check the... ＋

Agent reasoning

The denial is specifically that the billed new-patient E/M level was not supported, so I need to re-check the documented clinical work against the official E/M level criteria before using the final remaining submission. I will look up the 99202 requirements to confirm whether the current line is supportable or whether the service line must be changed to a different, non-E/M/urgent-care charge supported by the captured activity.

Args · stage denial · day 46

{"level": "99202"}

Result

{"code": "99202", "patient": "new", "mdm": "straightforward", "summary": "1 self-limited problem; minimal/none data; minimal risk."}

#36 kb_lookup_em_guidelines The denial is specific to the E/M level and notes that the documented ankle injury appears inconsistent with the... ＋

Agent reasoning

The denial is specific to the E/M level and notes that the documented ankle injury appears inconsistent with the previously billed straightforward new-patient level. I’m checking the official 99203 E/M criteria before changing the final remaining submission to a low-MDM new-patient visit level supported by an acute uncomplicated injury.

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."}

#37 set_service_lines The denial targets the E/M level, and the chart supports a new-patient urgent-care E/M for an acute uncomplicated... ＋

Agent reasoning

The denial targets the E/M level, and the chart supports a new-patient urgent-care E/M for an acute uncomplicated right ankle injury rather than the previously billed 99202. I will update the only service line to a different, MDM-supported E/M code before scrubbing and using the final submission attempt.

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 portal_download_era Before using the final available resubmission, I need to review the full ERA/EOB for the current denial to confirm... ＋

Agent reasoning

Before using the final available resubmission, I need to review the full ERA/EOB for the current denial to confirm the exact adjudication reason, line detail, and whether any payer-specific issue besides E/M level or missed charge reconciliation must be corrected.

Args · stage coding · 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-bd87ba050f", "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]

#39 run_scrub The prior denial specifically challenged the E/M level on 99202, and I have now re-derived the visit as a... ＋

Agent reasoning

The prior denial specifically challenged the E/M level on 99202, and I have now re-derived the visit as a new-patient urgent-care E/M with one acute uncomplicated injury and no separately billable orders/procedures. Before using the final submission, I need to scrub the corrected 99203 line and confirm there are no payer/NCCI/medical-necessity/header issues.

Args · stage coding · day 46

{}

Result

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

#40 kb_lookup_payer_policy The denial specifically says the E/M level and captured services do not match the chart, and the prior attempts... ＋

Agent reasoning

The denial specifically says the E/M level and captured services do not match the chart, and the prior attempts failed with S9083 and 99202. Before using the final submission, I need payer-specific guidance on whether this Oxford urgent-care professional claim should use standard E/M vs urgent-care global/case-rate rules and any required coding conventions.

Args · stage remittance · day 69

{}

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"}

#41 submit_claim The corrected claim now differs from both prior submissions, has been scrubbed clean, and the payer denial requires... ＋

Agent reasoning

The corrected claim now differs from both prior submissions, has been scrubbed clean, and the payer denial requires resubmission of the corrected E/M line. I will transmit the final available corrected 837P attempt and await 999/277CA/835 adjudication.

Args · stage closed_paid · day 69

{}

Result

{"ok": true, "result": "835_paid", "remit": {"remit_id": "era-49a919b534", "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]

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

Agent reasoning

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

Args · stage None · day None

{}

Result

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