High Priority Actions
Oldest held claim is 13 days. Primary causes: modifier conflict, POS mismatch, missing provider enrollment confirmation.
Stedi acceptance failed. Most common category: missing subscriber address and provider taxonomy.
Likely partial payment or contractual adjustment variance.
Financial Snapshot
| Metric | Value |
|---|---|
| Submitted today | $18,420 |
| Expected revenue | $126,112 |
| ERA received | $14,998 |
| Denied exposure | $11,840 |
Work Queues
Queue-Based Operating Model
Oldest / highest-risk first
Discourages cherry-picking and creates auditable operational sequencing.
Batch action concept
Select similar claims and apply controlled dispositions: assign, hold, request correction, resubmit.
Bottleneck visibility
Shows aging, owner, cause, and financial exposure by queue.
Patient / DOS
Helen Carter · DOB 1948 · DOS 05/13/2026 · Medicare FFS
Suggested Codes
CPT 99214, G0439 · ICD E11.9, I10 · Modifier 95 suggested by source packet.
Supporting Evidence
Structured note, telehealth modality, MDM summary, provider attestation, eligibility response.
| Line | CPT | Modifier | Charge |
|---|---|---|---|
| 1 | 99214 | 95 | $122 |
| 2 | G0439 | $184 |
Modifier mismatch
Modifier 25 may be required to support distinct E/M activity.
POS conflict
Encounter says telehealth; billing place of service requires biller confirmation.
Add modifier 25
Confidence 91%. Evidence: distinct evaluation language and separate medical decision complexity.
Denial Case: DEN-1042
| Field | Value |
|---|---|
| CARC/RARC | CARC 16 — Missing information |
| Financial impact | $184 |
| Aging | 12 days |
| Status | Needs rework |
Root Cause Probability
Missing modifier
Documentation gap
Eligibility issue
Appeal Packet Concept
Future state: generate appeal packet from evidence, denial code, claim history, and source documentation. Human approval required before submission.
ERA Reconciliation
Deposit match: Possible match found
| Claim | Expected | Paid | Variance | Likely Reason |
|---|---|---|---|---|
| CLM-204882 | $122 | $122 | $0 | Matched |
| CLM-204883 | $88 | $0 | -$88 | Denied |
| CLM-204884 | $220 | $180 | -$40 | Adjustment |
Claim Operational Timeline
Medicare FFS
Single-state MVP configuration. Commercial payers and MA preserved for future extension.
Enrollment + NPI
Operational view of enrollment status, rendering/billing provider details, taxonomy, and validity dates.
Configurable catalogs
Rules should be configurable rather than hardcoded, but MVP UI should remain simple.
Operational Flow View
82 held
67 denied