Inputs & data contract
835/ERA, claim/line detail, fee schedule or contract terms, modifiers, units, network status, adjustments and prior recovery history.
PRO · RCAI Agent Blueprint
Underpayment Detection Agent
Identify materially actionable differences between expected and actual reimbursement without flooding teams with false variance.
Payment Posted → Contract Matched → Expected Allowed Calculated → Variance Tested → Explained / Actionable / Manual Review → Recovery Queue → Resolved
Tool interfaces
ERA parser, contract/rate engine, PMS, payer rules, variance queue and audit/reconciliation layer.
Decision policy
Math and contract logic are deterministic. Model reasoning may classify unexplained variance and summarize evidence; it must never create missing contract terms.
Exception matrix
Multiple procedure logic; bundling; modifier effects; capitation; secondary payer; COB; contractual adjustments; fee-schedule ambiguity; retroactive rate changes.
Human-in-the-loop gates
Escalate missing/ambiguous contract terms, high-dollar variance, network-status conflicts and any recovery action requiring interpretation beyond supported terms.
Production KPIs
Precision of actionable variance; false-positive rate; dollars identified/recovered; recovery yield; analyst touches; time to detection.
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.