Inputs & data contract
Claim ID, DOS, billed amount, payer, member/provider IDs, submission timestamps, clearinghouse acknowledgements, prior touches, payer processing windows.
FREE · RCAI Agent Blueprint
Claim Status & A/R Follow-Up Agent
Determine the authoritative claim state and the next safe action while reducing avoidable manual touches.
Queued → Submitted → Accepted → Pending → Paid / Partially Paid / Denied / Records Requested / No Claim Found → Resolved or Escalated
Tool interfaces
PMS/PM API, clearinghouse 276/277, payer API or portal adapter, task queue, document workflow and audit log.
Decision policy
Use deterministic processing-window, duplicate, timely-filing and source-precedence rules before model reasoning. Never infer payment or resubmit a possible duplicate from ambiguous evidence.
Exception matrix
No claim found; portal/API unavailable; conflicting status; records requested; eligibility denial; partial payment; suspected underpayment; timely-filing risk.
Human-in-the-loop gates
Escalate destructive/financial actions, conflicting evidence, clinical/document requests without a mapped owner, repeat failures and low-confidence status normalization.
Production KPIs
Status accuracy; correct-next-action rate; false resubmission rate; touches avoided; days to resolution; dollars accelerated.
Evaluation plan
100-scenario plan spanning happy paths, payer delays, duplicates, ambiguous portal text, conflicting sources, partial payments, denials, downtime and adversarial inputs.
Implementation checklist
1) Map systems of record and authoritative evidence sources. 2) Implement deterministic validation and state transitions before model reasoning. 3) Define retry, timeout and idempotency behavior. 4) Create explicit HITL queues and owners. 5) Log source evidence, decisions and actions. 6) Run golden, edge and adversarial cases before go-live.
Downloadable implementation pack
Use the machine-readable starter files to move the blueprint into product, engineering or vendor-review work.
RCAI Blueprint Standard: production implementations should validate these specifications against the organization’s systems, payer contracts, policies, security requirements and operating controls before autonomous action.