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Trajectory · Claim #95187 · trial 3

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 payer-portal access before verifying coverage and later retrieving any ERA/EOB, so I am starting the... ＋

Agent reasoning

I need payer-portal access before verifying coverage and later retrieving any ERA/EOB, so I am starting the Healthfirst portal login workflow. This should trigger the OTP step needed to authenticate.

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 any payer-specific checks can be performed.... ＋

Agent reasoning

I need to complete payer portal access before eligibility/benefits and any payer-specific checks can be performed. The portal login already issued 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 confirm the member’s coverage is active for the DOS and identify any... ＋

Agent reasoning

Before coding or billing, I need to confirm the member’s coverage is active for the DOS and identify any COB/primary-payer issues from the 271 response.

Args · stage eligibility · day 0

{}

Result

{"ok": true, "coverages": [{"rank": "primary", "payer": "HEALTHFIRST OF NEW YORK GR", "member_id": "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 perform the required documentation review from the source chart before assigning ICD-10-CM/CPT codes. I... ＋

Agent reasoning

I need to perform the required documentation review from the source chart before assigning ICD-10-CM/CPT codes. I will open the progress note to confirm the documented condition, exam, orders, time, and any ambiguity needing a provider query.

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 I need to complete the coder documentation review before assigning diagnoses or E/M level, and identify whether any... ＋

Agent reasoning

I need to complete the coder documentation review before assigning diagnoses or E/M level, and identify whether any ambiguity requires a provider query. This should confirm whether the eczema documentation is sufficient or needs clarification before coding.

Args · stage documentation · day 0

{}

Result

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

#5 capture_charges Coverage and documentation review are already complete, and there are no open provider queries. Next I need to... ＋

Agent reasoning

Coverage and documentation review are already complete, and there are no open provider queries. Next I need to aggregate all 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_icd10 I need to translate the documented SNOMED/problem description of lifelong eczema/dry skin into an ICD-10-CM... ＋

Agent reasoning

I need to translate the documented SNOMED/problem description of lifelong eczema/dry skin into an ICD-10-CM diagnosis before building the claim. The note does not document a specific eczema subtype, so I am verifying the nonspecific dermatitis/eczema code rather than assuming atopic dermatitis.

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."}

#7 kb_coding_guidelines Before setting Box 24, I need the payer/workflow rule for translating the captured urgent-care activity into the... ＋

Agent reasoning

Before setting Box 24, I need the payer/workflow rule for translating the captured urgent-care activity into the correct service code family, because the charge feed has no CPT codes and may require a UC global/case-rate code rather than a standard E/M line. I will review service-line coding rules to avoid burning a submission with the wrong code type.

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_coding_guidelines Before setting service lines, I need to confirm whether this payer/urgent-care workflow requires the urgent-care... ＋

Agent reasoning

Before setting service lines, I need to confirm whether this payer/urgent-care workflow requires the urgent-care global case-rate HCPCS instead of a standard new-patient E/M. I will check the urgent-care coding guidance to map the captured clinical activity correctly and avoid burning a submission.

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]

#9 kb_lookup_em_guidelines I need to level the new-patient E/M correctly from the documented MDM rather than defaulting, since there are no... ＋

Agent reasoning

I need to level the new-patient E/M correctly from the documented MDM rather than defaulting, since there are no procedures, labs, drugs, or orders. I will check the E/M guideline thresholds for 99203 to determine whether the chronic eczema visit supports low MDM or should be downgraded.

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."}

#10 kb_lookup_cpt The visit is an urgent care new-patient encounter with one captured activity, and the workflow notes warn that an... ＋

Agent reasoning

The visit is an urgent care new-patient encounter with one captured activity, and the workflow notes warn that an urgent_care_global activity should be billed as the urgent-care global case-rate HCPCS rather than a separate E/M. I’m verifying the HCPCS description before setting the service line.

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"]}

#11 set_diagnoses The diagnosis has been clinically mapped to unspecified eczema/dermatitis from the documented lifelong eczema and... ＋

Agent reasoning

The diagnosis has been clinically mapped to unspecified eczema/dermatitis from the documented lifelong eczema and verified previously; the captured urgent-care activity should be billed as the payer’s urgent-care global case-rate rather than a separate E/M. I will now set the ICD-10 diagnosis in Box 21 primary-first so service-line linkage can be completed next.

Args · stage coding · day 0

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

Result

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

#12 set_service_lines The only captured billable activity is the urgent-care new-patient encounter with no separately ordered labs,... ＋

Agent reasoning

The only captured billable activity is the urgent-care new-patient encounter with no separately ordered labs, imaging, procedures, or drugs. Per the urgent-care guidance already checked, this should be billed as the urgent-care global case-rate service rather than a separate office E/M line, linked to the established eczema diagnosis with POS 20.

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

Agent reasoning

The claim currently has active coverage, COB resolved, diagnosis and urgent-care global service line set, with no ordered labs/imaging, drugs, or prior authorization indicated. I will run the pre-submission scrub now to catch any payer, NCCI, modifier, medical-necessity, NDC, taxonomy, or header 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, 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. There are no ordered labs/imaging, drugs/NDCs, or prior-auth-required services, so the next step is to transmit the initial 837P and obtain payer intake/remittance results.

Args · stage denial · day 38

{}

Result

{"ok": false, "result": "835_denied", "remit": {"remit_id": "era-d927e640aa", "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-f8a7c1df85", "stage": "adjudication", "s …[truncated]

#15 kb_lookup_carc The claim denied for CO-16/M51 on the S9083 line, so I need to confirm the denial meaning and payer-correction path... ＋

Agent reasoning

The claim denied for CO-16/M51 on the S9083 line, so I need to confirm the denial meaning and payer-correction path before changing the service line. This should clarify whether the issue is an invalid/unsupported procedure code versus missing claim data.

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"}

#16 portal_download_era The claim denied at adjudication with CO-16/M51, and before changing the CPT I need to review the full ERA/EOB to... ＋

Agent reasoning

The claim denied at adjudication with CO-16/M51, and before changing the CPT I need to review the full ERA/EOB to confirm the payer’s exact line-level denial details and whether any additional remark codes or payment policy notes apply. This will prevent wasting a remaining resubmission attempt.

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-d927e640aa", "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]

#17 kb_lookup_em_guidelines The denial specifically says S9083 is an invalid/unsupported procedure for the documented service, so I need to... ＋

Agent reasoning

The denial specifically says S9083 is an invalid/unsupported procedure for the documented service, so I need to re-level the actual new-patient E/M from the chart before changing the line. I’m checking the E/M rules for the likely replacement code to confirm whether the 15-minute new urgent-care visit and limited MDM support 99202 rather than a higher level.

Args · stage denial · day 38

{"level": "99202"}

Result

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

#18 kb_lookup_cpt The denial rejected S9083 as invalid/unsupported for the documented encounter, so I need to replace it with the... ＋

Agent reasoning

The denial rejected S9083 as invalid/unsupported for the documented encounter, so I need to replace it with the documented professional E/M service. Before changing the claim, I’m verifying CPT 99202 as the new-patient straightforward MDM office/urgent-care E/M code supported by the chart.

Args · stage denial · day 38

{"code": "99202"}

Result

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

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

Agent reasoning

The denial specifically rejects S9083 as unsupported, so I need to replace it with the documented new-patient office/outpatient E/M level. Before changing the line, I am checking whether 99203 could be supported by the documented chronic eczema problem or whether the claim should remain at straightforward 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."}

#20 set_service_lines The denial is specific to unsupported HCPCS S9083; the chart documents only a new patient urgent-care evaluation for... ＋

Agent reasoning

The denial is specific to unsupported HCPCS S9083; the chart documents only a new patient urgent-care evaluation for eczema/dry skin with no separately billable orders, procedures, drugs, or supplies. I am replacing the denied case-rate code with the supported new-patient office/other outpatient E/M code at the documented 15-minute/straightforward level, keeping POS 20 and the eczema diagnosis pointer.

Args · stage coding · day 38

{"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 line was for unsupported S9083; the claim has been corrected to the documented new-patient urgent-care... ＋

Agent reasoning

The denied line was for unsupported S9083; the claim has been corrected to the documented new-patient urgent-care E/M 99202 with dx pointer to L30.9. Before using another submission attempt, I need to run the payer scrub to confirm CPT, POS, diagnosis linkage, modifiers, NCCI/MUE, and header requirements are clean.

Args · stage coding · day 38

{}

Result

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

#22 submit_claim The denied first submission used S9083, but the corrected claim now has the documented new-patient E/M 99202 linked... ＋

Agent reasoning

The denied first submission used S9083, but the corrected claim now has the documented new-patient E/M 99202 linked to L30.9, POS 20, no ordered services, no drug/NDC lines, no auth requirement, and the scrub is clean. This resubmission differs from the denied coding and should adjudicate correctly.

Args · stage remittance · day 76

{}

Result

{"ok": true, "result": "835_paid", "remit": {"remit_id": "era-333c33e817", "status": "paid", "billed_cents": 12600, "allowed_cents": 12500, "paid_cents": 12500, "patient_resp_cents": 0, "contractual_cents": 100, "claim_control_number": "CCN95187-2", "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]

#23 post_remittance The corrected claim has already returned a paid 835 with $125.00 paid and $0.00 patient responsibility, but the ERA... ＋

Agent reasoning

The corrected claim has already returned a paid 835 with $125.00 paid and $0.00 patient responsibility, but the ERA is not yet posted. I will post the remittance to reconcile the contractual adjustment and close out the remaining checklist item.

Args · stage closed_paid · day 76

{}

Result

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