Inputs & data contract
835/EOB, CARC/RARC, claim history, payer, code/modifier data, authorization/eligibility evidence, contract context and filing deadlines.
PRO · RCAI Agent Blueprint
Denial Classification & Appeal Agent
Classify denials into an operational root cause, determine recoverability and route the correct resolution or appeal action.
Denial Received → Normalized → Root Cause Classified → Recoverability Assessed → Correct / Appeal / Write-off Review / Escalate → Submitted → Resolved
Tool interfaces
ERA parser, PMS, document store, payer policy source, appeal workflow, task queue and audit log.
Decision policy
Use codes and structured claim evidence first; model reasoning may summarize evidence and select among supported pathways but cannot fabricate payer policy or clinical facts.
Exception matrix
Bundling; medical necessity; eligibility; authorization; duplicate; frequency; non-covered; max benefit; timely filing; documentation; coding/edit conflicts.
Human-in-the-loop gates
Require human approval for clinical arguments, unsupported payer-policy interpretation, write-offs above threshold, conflicting evidence and low-confidence root cause.
Production KPIs
Classification precision; recoverability precision; correct-action rate; appeal overturn rate; avoidable denial recurrence; net dollars recovered.
Production implementation pack
Use the state model above as the control plane. The production pack adds transition guards, source precedence, retry/idempotency rules, exception ownership, audit requirements, evaluation cases and go-live acceptance thresholds.
Evaluation & acceptance
Validate classification and next-action accuracy separately. Track unsafe autonomous actions as a zero-tolerance metric, regression-test every rule or model change, and require supported evidence for every payer-specific conclusion.
Pro implementation note: adapt the blueprint to your contracts, payer policies, systems, security model and approval thresholds before production autonomy.