Claims and Appeals Automation

Claims and appeals flows combine high volume with strict auditability requirements.

Use case goals

• Reduce manual queue handling time
• Improve throughput for repetitive claim follow-up tasks
• Preserve evidence trail for payer and compliance review

Recommended pipeline

1. Import claim queue with required identifiers.
2. Execute workflow to gather payer state and required artifacts.
3. Flag exceptions with reason taxonomy.
4. Export structured outcomes for downstream systems.

Pilot metrics to track

• Claim completion rate
• Flagged ratio by reason category
• Time saved vs manual baseline
• Cost per workflow run

Appeals-specific guidance

• Store appeal package references per case.
• Capture stop events with expected vs actual UI state.
• Provide operator review queue for flagged outcomes.
• For dental claim attachment readiness, run deterministic Scope -> Validate -> Gather -> Review -> Queue; use Gather outputs that prioritize procedure-linked teeth, then fallback to note-derived teeth from the claim service date only when needed, then fallback to same-day DEXIS images as last resort when explicit tooth linkage is missing, classify prosthesis context (initial vs replacement) from prior tooth history, surface provider-authored evidence-of-need phrases, and capture explicit approve/hold/skip decisions per claim.
• Classify holds into mutually exclusive issue buckets (Clinical notes, Attachments, Provider mismatch, Codes and ledger, Missing info, Other).
• Publish concise next-action guidance that operators can execute immediately (mark reviewed or mark complete, based on claim state).

Evidence and reporting

For partner audits, maintain:

• Batch-level completion summaries
• Queue-level issue and trend summaries from /app/org-dashboard/{orgKey} and /app/org-dashboard/{orgKey}/analytics
• Screenshot evidence for exceptions
• Export records aligned with contractual KPI definitions