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Trajectory · Claim #95187 · 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 · 28 tool calls

#0 portal_login I need to access the payer portal before verifying eligibility and claim requirements for Healthfirst. This should... ＋

Agent reasoning

I need to access the payer portal before verifying eligibility and claim requirements for Healthfirst. This should initiate the login workflow and OTP process.

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/benefits and later ERA retrieval can be performed. The... ＋

Agent reasoning

I need to complete payer portal access before eligibility/benefits and later ERA retrieval can be performed. The portal login has already sent the simulated OTP, so I will verify it now.

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 through the payer 270/271 transaction and identify any... ＋

Agent reasoning

Before coding or billing, I need to verify active coverage through the payer 270/271 transaction and identify any COB or patient-responsibility information that may affect primary payer selection.

Args · stage eligibility · day 0

{}

Result

{"ok": true, "coverages": [{"rank": "primary", "payer": "HEALTHFIRST OF NEW YORK GR", "member_id": "MD7B81D3E7", "group": "GRP-4677", "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 documentation before coding to confirm the complaint, exam, diagnoses, orders, and... ＋

Agent reasoning

I need to review the source documentation before coding to confirm the complaint, exam, diagnoses, orders, and whether any ambiguity requires a provider query. I will start with the progress note because it contains the clinical narrative and any documented billable activity.

Args · stage eligibility · day 0

{"section": "progress_note"}

Result

{"section": "progress_note", "body": "### [visit]\nDate:   |  Start Time: 14:46:00  |  End Time: 15:01:00  |  Length of Stay: 15 min  |  Reason: Dry skin on hand and face  |  Visit type: NCH - NEW\nProvider: \n\nStatus: CHK\n\n### [clinical_note_(free_text)]\nGeneral: pt has eczema all his life and needs cream for it\n[EXTREMITIES:] no clubbing, cyanosis, or edema\n[SKIN:] dry, atrophic skin noted to bilateral hands over mcp joints\n[NEUROLOGIC:] nonfocal, motor strength normal  …[truncated]

#4 review_documentation Eligibility is already verified, so the next required step is coder documentation review to identify any ambiguity,... ＋

Agent reasoning

Eligibility is already verified, so the next required step is coder documentation review to identify any ambiguity, missing elements, or query needs before coding and charge capture. I expect this to confirm whether the eczema documentation is sufficient and whether a provider query is required.

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 provider queries. Next I need to aggregate... ＋

Agent reasoning

Eligibility and documentation review are complete, and there are no open provider queries. Next I need to aggregate the billable activities from the chart/charge feed before assigning CPT/HCPCS service lines.

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 I need to level the new-patient E/M from documented MDM rather than defaulting; the chart shows one lifelong... ＋

Agent reasoning

I need to level the new-patient E/M from documented MDM rather than defaulting; the chart shows one lifelong eczema/dermatitis problem with no documented time, orders, or procedures. I will check the 2021 requirements for the likely low-MDM new-patient level before committing CPT coding.

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_coding_guidelines Before setting service lines, I need to confirm the payer/workflow rule for the captured urgent-care activity... ＋

Agent reasoning

Before setting service lines, I need to confirm the payer/workflow rule for the captured urgent-care activity because the charge feed has activity rather than codes and may require an urgent-care global HCPCS instead of a standard office E/M. I will check the service-line coding rules to make sure the CPT/HCPCS family is correct before committing the claim.

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_icd10 The documented condition is chronic eczema/dry atrophic skin without a more specific dermatitis type, laterality... ＋

Agent reasoning

The documented condition is chronic eczema/dry atrophic skin without a more specific dermatitis type, laterality complication, or acuity documented. I will verify the ICD-10-CM code for unspecified dermatitis/eczema before setting Box 21.

Args · stage charge_capture · day 0

{"code": "L30.9"}

Result

{"code": "L30.9", "found": false, "note": "Description only - confirm this is the specific code the documentation supports before committing it."}

#9 kb_lookup_icd10 The chart documents lifelong eczema/dry atrophic skin, so I need to verify whether atopic dermatitis unspecified is... ＋

Agent reasoning

The chart documents lifelong eczema/dry atrophic skin, so I need to verify whether atopic dermatitis unspecified is a valid, more specific ICD-10-CM option than unspecified dermatitis before setting Box 21.

Args · stage charge_capture · day 0

{"code": "L20.9"}

Result

{"code": "L20.9", "found": false, "note": "Description only - confirm this is the specific code the documentation supports before committing it."}

#10 kb_lookup_payer_policy Before setting service lines, I need confirm this payer’s urgent-care billing rule because the captured charge... ＋

Agent reasoning

Before setting service lines, I need confirm this payer’s urgent-care billing rule because the captured charge appears to be an urgent-care visit and the instructions warn that some UC activity bills as a global case-rate HCPCS rather than a standard E/M. This should tell me whether to use an E/M code or an urgent-care HCPCS and any required taxonomy/POS/auth rules.

Args · stage charge_capture · 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"}}

#11 kb_lookup_cpt The captured activity appears to be an urgent-care global/case-rate service rather than a separately billed office... ＋

Agent reasoning

The captured activity appears to be an urgent-care global/case-rate service rather than a separately billed office E/M. I need to verify the HCPCS description before setting the service line so I do not burn a submission with the wrong code family.

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 only documented diagnosis is lifelong eczema/dry/atrophic skin of the hands/face without documentation of atopic... ＋

Agent reasoning

The only documented diagnosis is lifelong eczema/dry/atrophic skin of the hands/face without documentation of atopic type, infected dermatitis, contact trigger, or other specificity. I will set the ICD-10-CM diagnosis to unspecified dermatitis/eczema as the primary diagnosis before building the service line.

Args · stage coding · day 0

{"codes": ["L30.9"]}

Result

{"ok": true, "diagnoses": [{"sequence": 1, "code": "L30.9"}]}

#13 set_service_lines The chart/charge capture supports a single urgent-care encounter with no separate procedures, drugs, labs, or... ＋

Agent reasoning

The chart/charge capture supports a single urgent-care encounter with no separate procedures, drugs, labs, or imaging, and this payer/provider setup uses the urgent-care global case-rate rather than a separate fee-for-service E/M. I will set one Box 24 line for S9083 with POS 20 and the dermatitis diagnosis pointer so the claim can be scrubbed next.

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 has eligibility, COB, diagnosis, provider taxonomy, and the urgent-care global service line set with no... ＋

Agent reasoning

The claim has eligibility, COB, diagnosis, provider taxonomy, and the urgent-care global service line set with no ordered labs/imaging, drugs, or auth-required services. I’m running the pre-submission scrub now to catch any payer/NCCI/medical-necessity/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 The claim has active primary Healthfirst coverage, no COB issue, no ordered services requiring referring NPI or... ＋

Agent reasoning

The claim has active primary Healthfirst coverage, no COB issue, no ordered services requiring referring NPI or prior authorization, provider identity is set, diagnosis/service line coding is scrub-clean, and no submissions have been used. I will submit the first 837P now and expect payer intake/ERA results.

Args · stage denial · day 38

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-04e47ae738", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN95187-1", "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-d3e9971f45", "stage": "adjudication", "s …[truncated]

#16 kb_lookup_carc The denial specifically cites CARC CO-16 with RARC M51 for an invalid/missing procedure code on S9083. I will... ＋

Agent reasoning

The denial specifically cites CARC CO-16 with RARC M51 for an invalid/missing procedure code on S9083. I will confirm the denial meaning and payer remedy before changing the service line so the corrected resubmission does not waste another attempt.

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"}

#17 portal_download_era The payer denied the submitted urgent-care global code S9083 as invalid/unsupported for the documented service, and... ＋

Agent reasoning

The payer denied the submitted urgent-care global code S9083 as invalid/unsupported for the documented service, and before burning a resubmission I need the full ERA/EOB detail to confirm the exact adjudication issue and whether any payer-specific remark affects the corrected coding approach.

Args · stage denial · day 38

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN95187-1\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-04e47ae738", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN95187-1", "line …[truncated]

#18 kb_lookup_em_guidelines The denial is specifically for unsupported S9083, so I need to re-level the documented new-patient urgent-care E/M... ＋

Agent reasoning

The denial is specifically for unsupported S9083, so I need to re-level the documented new-patient urgent-care E/M from MDM/time before replacing the line. I am checking 99203 criteria because the chart documents a chronic eczema complaint/problems addressed with no separately billable procedures or orders, and I need to confirm whether low MDM is supportable versus 99202.

Args · stage denial · day 38

{"level": "99203"}

Result

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

#19 set_service_lines The denial identified S9083 as unsupported/invalid for this documented encounter, so I am replacing the denied... ＋

Agent reasoning

The denial identified S9083 as unsupported/invalid for this documented encounter, so I am replacing the denied urgent-care global code with the documented new-patient office/urgent-care E/M service. The chart supports a new patient E/M visit for chronic eczema/dry skin, with no separately billable orders, drugs, labs, imaging, or procedures.

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": ""}]}

#20 run_scrub The denied S9083 line has been corrected to a documented new-patient E/M service (99203), so before using another... ＋

Agent reasoning

The denied S9083 line has been corrected to a documented new-patient E/M service (99203), so before using another submission attempt I need to re-run the claim scrub to confirm the corrected CMS-1500/837P passes payer and coding edits. I expect this to identify any remaining NCCI, modifier, POS, diagnosis-pointer, medical-necessity, or header issues before resubmission.

Args · stage coding · day 38

{}

Result

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

#21 submit_claim The initial denial was specifically for the unsupported S9083 urgent-care global code. The claim has been corrected... ＋

Agent reasoning

The initial denial was specifically for the unsupported S9083 urgent-care global code. The claim has been corrected to a new-patient E/M service 99203 with diagnosis L30.9, POS 20, scrub is clean, and there are no ordered labs/imaging, drugs, or prior-auth requirements to add, so the next step is to resubmit the corrected 837P.

Args · stage denial · day 76

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-680696d651", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN95187-2", "lines": [{"cpt": "99203", "billed_cents": 10000, "paid_cents": 0, "carc": "CO-150", "rarcs": ["M25"]}], "carcs": ["CO-150"], "rarcs": ["M25"], "posted": false, "transaction": "835"}, "denial": {"denial_id": "den-9597b242ab", "stage": "adjudication",  …[truncated]

#22 kb_lookup_em_guidelines The payer denied 99203 as unsupported; the documented encounter is a new-patient urgent care visit with only one... ＋

Agent reasoning

The payer denied 99203 as unsupported; the documented encounter is a new-patient urgent care visit with only one uncomplicated skin complaint, no orders, and a 15-minute visit length, so I need to verify whether 99202 is the supported E/M level before using the final submission attempt.

Args · stage denial · day 76

{"level": "99202"}

Result

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

#23 set_service_lines The denial specifically states the new-patient E/M level 99203 is not supported. Based on the documented single... ＋

Agent reasoning

The denial specifically states the new-patient E/M level 99203 is not supported. Based on the documented single uncomplicated eczema/dermatitis complaint, no documented orders, no separately billable procedures/drugs, and no documented prescription management, the supported level is straightforward MDM, so I am correcting the service line to 99202 before the final scrub/resubmission.

Args · stage coding · day 76

{"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": ""}]}

#24 portal_download_era The second submission denied at adjudication, and before using the final submission attempt I need to read the full... ＋

Agent reasoning

The second submission denied at adjudication, and before using the final submission attempt I need to read the full 835 ERA/EOB details to confirm the exact denied line, CARC/RARC context, and whether any other claim elements require correction beyond E/M level.

Args · stage coding · day 76

{}

Result

{"ok": true, "era_text": "835 ERA / EOB   CCN=CCN95187-2\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    99203: billed $100.00 paid $0.00 PR $0.00  [DENIED CO-150 M25]", "era": {"remit_id": "era-680696d651", "status": "denied", "billed_cents": 10000, "allowed_cents": 0, "paid_cents": 0, "patient_resp_cents": 0, "contractual_cents": 10000, "claim_control_number": "CCN95187-2", "li …[truncated]

#25 run_scrub The denied line was 99203 as unsupported, and the claim has already been corrected to 99202 for a new-patient urgent... ＋

Agent reasoning

The denied line was 99203 as unsupported, and the claim has already been corrected to 99202 for a new-patient urgent care visit with limited documented MDM/time. Before using the final available submission, I need to rerun the payer scrub on the corrected 99202 claim to confirm there are no NCCI, modifier, medical-necessity, POS, or header issues.

Args · stage coding · day 76

{}

Result

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

#26 submit_claim The denial was for unsupported 99203; the chart supports a new-patient urgent care E/M at 99202 for a single... ＋

Agent reasoning

The denial was for unsupported 99203; the chart supports a new-patient urgent care E/M at 99202 for a single straightforward eczema problem with no documented orders, procedures, drugs, or prescription management. The claim now differs from both prior failed submissions, has diagnosis L30.9 linked to 99202 POS 20, and the scrub is clean, so I will use the final allowed submission.

Args · stage remittance · day 114

{}

Result

{"ok": true, "result": "835_paid", "remit": {"remit_id": "era-ce5185a96f", "status": "paid", "billed_cents": 12600, "allowed_cents": 12500, "paid_cents": 12500, "patient_resp_cents": 0, "contractual_cents": 100, "claim_control_number": "CCN95187-3", "lines": [{"cpt": "99202", "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]

#27 post_remittance The third submission has returned a paid 835 for the corrected 99202 claim, and the only remaining checklist item is... ＋

Agent reasoning

The third submission has returned a paid 835 for the corrected 99202 claim, and the only remaining checklist item is to post the remittance and reconcile the $0 patient responsibility. I will post the ERA payment and contractual adjustment to close the revenue-cycle work for this claim.

Args · stage closed_paid · day 114

{}

Result

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