Live Agent Demo

Claims Exception Handling

Watch an autonomous agent investigate complex claims anomalies, pull historical context from the Enterprise Memory Layer, and resolve — or strategically escalate — each exception without touching a human review queue.

Agentic AI Enterprise Memory Simulated

Claims Batch Ingested

Scanning

Payer SilverCare MA (HMO)

Batch ID CLM-2025-0318-B04

Claims in Batch 9

Flags Triggered 4

agent > ingest_claims_batch(batch_id="CLM-2025-0318-B04", source="835-EDI", apply_rules=True, flag_anomalies=True)

Claim ID	Member	Provider	Procedure	Billed	Status
`CLM-7741`	D. Rivera	Northside Surgical	CPT 27447 (TKR)	$48,200	Exception
`CLM-7742`	E. Thornton	Valley Dialysis Ctr	CPT 90960 (HD×3)	$12,450	Exception
`CLM-7743`	M. Okafor	HealthFirst PCP	CPT 99213 (Office)	$195	Clean
`CLM-7744`	S. Russo	Metro Lab Partners	CPT 80053 (CMP)	$2,180	Exception
`CLM-7745`	A. Patel	HealthFirst PCP	CPT 99214 (Office)	$285	Clean
`CLM-7746`	L. Washington	Cardio Associates	CPT 93000 (EKG)	$320	Clean
`CLM-7747`	J. Kim	Riverside Oncology	CPT 96413 (Chemo)	$31,500	Exception
`CLM-7748`	B. Adeyemi	HealthFirst PCP	CPT 99203 (New Pt)	$220	Clean
`CLM-7749`	F. Nguyen	HeartCare Specialists	CPT 93306 (Echo)	$1,840	Clean

9 claims processed — 4 flagged as exceptions (CLM-7741, CLM-7742, CLM-7744, CLM-7747). Routing to anomaly detection engine…

Anomaly Classification

AI Reasoning

agent > classify_anomalies(claims=["CLM-7741","CLM-7742","CLM-7744","CLM-7747"], rules=["coverage","duplicate","unbundling","auth","clinical_criteria"])

Claim ID	Anomaly Type	Rule Triggered	Confidence	Prior Auth?	Severity
`CLM-7741` TKR · $48,200	Missing Auth High-cost outlier	Rule R-114: PA required >$15k surgical procedures	94%	No	Critical
`CLM-7742` Dialysis × 3 · $12,450	Frequency outlier Billing pattern	Rule R-209: HD sessions exceed 3/wk without CKD-5 on file	81%	Yes	High
`CLM-7744` Comp Metabolic · $2,180	Duplicate candidate	Rule R-042: CMP billed 3× in 30 days for same member	88%	N/A	Medium
`CLM-7747` Chemo infusion · $31,500	Clinical mismatch Missing diagnosis	Rule R-318: Oncology CPT without active malignancy ICD-10 on member record	97%	Conditional	Critical

2 critical exceptions identified. Querying Enterprise Memory Layer for historical context on CLM-7741 (prior auth history) and CLM-7747 (oncology diagnosis records)…

Enterprise Memory Layer Query

Memory Recall

agent > memory.query(claims=["CLM-7741","CLM-7747"], context=["prior_auth","diagnosis_history","provider_pattern","appeals"], lookback_days=365)

The Enterprise Memory Layer retrieved historical context that is directly material to resolving each exception — without routing to a human reviewer.

CLM-7741 — D. Rivera · TKR $48,200

3 matching memory records retrieved

Prior Authorization — Issued 47 days ago

PA #SCA-2025-0129: Total knee replacement (CPT 27447), provider Northside Surgical, authorized for D. Rivera. Approved 2025-01-29, valid through 2025-06-30. Auth was issued under a different claim submission that was voided due to facility code error — never reattached.

Strong match

Orthopedic referral — 63 days ago

Referral REF-9921 from PCP Dr. Chen → Northside Surgical for severe osteoarthritis bilateral knees. ICD-10: M17.11. Referral active and valid at time of procedure.

Strong match

Provider credentialing — current

Northside Surgical (NPI 1234567890) is an in-network contracted facility. Orthopedic surgery rates are covered under current contract. No fraud/abuse flags on file.

Strong match

CLM-7747 — J. Kim · Chemo Infusion $31,500

2 matching memory records retrieved

Oncology diagnosis — not found in plan records

Member J. Kim has no active malignancy ICD-10 code in the plan's claim history or EMR feed. Last clinical encounter (2024-04-11) shows T2DM and HTN only. No oncology specialist referral on file from any covered provider.

No match

Provider billing pattern — anomalous

Riverside Oncology has had 3 similar claims in the past 90 days for members with no oncology diagnosis on file. Two of those claims were subsequently denied and not appealed. Pattern consistent with diagnosis code omission or billing error.

Pattern flag

Memory context retrieved. CLM-7741 has a valid orphaned auth — autonomous correction possible. CLM-7747 lacks clinical basis — requires strategic escalation. Proceeding to clinical assessment…

Instantaneous Clinical Criteria Assessment

Clinical AI

agent > assess_clinical_criteria(claims=["CLM-7741","CLM-7742","CLM-7744","CLM-7747"], guidelines=["InterQual","CMS-LCD","plan_policy"], include_memory=True)

CLM-7741 — Total Knee Replacement

D. Rivera · Northside Surgical · CPT 27447 · $48,200

Auto-Resolvable

InterQual Criteria

Severe bilateral OA (M17.11) meets criteria for TKR. Conservative therapy documented >6 months. Functional limitation confirmed. ✓ Criteria met

Auth Reconciliation

PA #SCA-2025-0129 recovered from memory — valid, unexpired, procedure-matched. Exception is an administrative orphan, not a true clinical denial. ✓ Correctable

Agent assessment: The missing-auth flag is a system artifact — the authorization exists but was orphaned during a prior claim void. Clinical necessity is fully supported. This exception can be autonomously corrected by re-linking PA #SCA-2025-0129 to CLM-7741 and reprocessing without human intervention.

CLM-7742 — Hemodialysis × 3 sessions

E. Thornton · Valley Dialysis Ctr · CPT 90960 · $12,450

Auto-Resolvable

Diagnosis Verification

Memory confirms CKD Stage 3 (N18.3) on file — progression note from nephrology dated 2024-11-14 documents initiation of dialysis preparation. ✓ Diagnosis supported

Frequency Rule

Rule R-209 triggered on CKD-5 check, but member has active CKD-3 with documented ESRD trajectory. Rule uses stale stage code. ⚠ Rule outdated

Agent assessment: The frequency exception was triggered by an outdated staging rule. Clinical basis is sound — CKD-3 progression to dialysis is documented and clinically supported. Agent will correct the rule parameter mismatch and approve automatically. Rule R-209 flagged for policy update.

CLM-7744 — Comprehensive Metabolic Panel × 3

S. Russo · Metro Lab Partners · CPT 80053 · $2,180

Auto-Resolvable

Duplicate Check

3 CMP tests confirmed across 3 separate ordering providers (PCP, nephrologist, cardiologist). Each has a distinct NPI and ordering diagnosis. Not a duplicate — multi-provider medically necessary monitoring. ✓ Distinct claims

Medical Necessity

S. Russo has T2DM, CKD-2, HTN — CMP monitoring at 2–4 week intervals is within clinical guidelines for multi-comorbidity management. ✓ Medically necessary

Agent assessment: The duplicate flag was a false positive — three different ordering physicians each submitted a clinically justified CMP. Agent will clear the exception and approve all three claims. Rule R-042 flagged for multi-provider carve-out refinement.

CLM-7747 — Chemotherapy Infusion

J. Kim · Riverside Oncology · CPT 96413 · $31,500

Strategic Escalation

Clinical Criteria

No active malignancy ICD-10 in member record, EMR feed, or claims history. Oncology referral absent. Clinical necessity cannot be established from available data. ✗ Criteria not met

Provider Pattern

Riverside Oncology shows a 3-claim pattern of oncology billing without diagnosis support. Two prior similar claims denied and not appealed — consistent with systematic coding omission or potential fraud signal. ✗ Pattern risk

Agent assessment: Autonomous resolution is not appropriate here. The absence of a clinical basis, combined with a provider billing pattern, makes this a candidate for strategic escalation to the Special Investigations Unit (SIU) — not routine human review. Agent will hold the claim, generate a structured SIU referral package, and deny pending investigation.

Clinical assessment complete. 3 exceptions auto-resolvable, 1 requires strategic SIU escalation. Executing resolutions now…

Autonomous Resolution & Strategic Escalation

Resolving

agent > resolve_exceptions(auto=["CLM-7741","CLM-7742","CLM-7744"], escalate_siu=["CLM-7747"], hold_payment=True)

CLM-7741 D. Rivera · TKR · $48,200

Auto-Resolved

Approved — Auth re-linked and claim reprocessed

PA #SCA-2025-0129 was recovered from the Enterprise Memory Layer and re-attached to CLM-7741. Clinical criteria (InterQual) confirmed. Claim reprocessed at contracted rate — $48,200 approved for payment. No human reviewer required. Administrative root cause logged for system remediation.

Auth re-linked Payment approved Root cause flagged

CLM-7742 E. Thornton · Dialysis × 3 · $12,450

Auto-Resolved

Approved — Rule parameter corrected, frequency exception cleared

Rule R-209 was triggered against an outdated CKD stage requirement. Agent corrected the staging lookup against current ICD-10 coding standards. Dialysis frequency is clinically justified by documented CKD progression. $12,450 approved. Rule R-209 queued for policy team review.

Rule R-209 corrected Payment approved Policy update queued

CLM-7744 S. Russo · CMP × 3 · $2,180

Auto-Resolved

Approved — False positive cleared, all three claims payable

Duplicate flag was based on member ID alone without provider differentiation. Agent confirmed three distinct ordering NPIs with independent clinical justification. All three CMP claims ($727 each) approved. Rule R-042 updated with multi-provider carve-out logic to prevent recurrence.

False positive cleared $2,180 approved Rule R-042 patched

CLM-7747 J. Kim · Chemo · $31,500

SIU Escalated

Denied & escalated to Special Investigations Unit

No clinical basis established. Provider billing pattern flagged across 3 members. Structured SIU referral package generated automatically — includes claim details, member history, provider pattern analysis from memory layer, and recommended investigation scope. Payment held pending outcome. Member notified per regulatory timeline.

Payment held SIU referral filed Provider flagged Member notified

AI decision — human override available

Human Override — CLM-7747 · J. Kim · Chemo Infusion · $31,500

Select Decision

Approve for Payment

Escalate to P2P Review

Request Additional Documentation

Keep SIU Escalation

Override Reasoning

Agent re-evaluating with human override…

Override will be logged in the audit trail with your identity and timestamp.

Audit Trail & Batch Summary

Complete

$62,830 Resolved autonomously (3 claims)

75% Auto-resolution rate (no human needed)

1 SIU escalation (strategic, not routine)

<90 sec End-to-end processing time

Batch CLM-2025-0318-B04 Ingested

9 claims processed via 835-EDI. 4 anomaly flags triggered. 5 claims approved clean on first pass.