# Claims-Denial Case — Mission 1 Evidence

Open this first. Do not open later-stage evidence until you complete the Mission 1
artifact. This fictional source set supports synthetic practice; it cannot prove
field observation, customer authority, or production readiness.

## Case brief

Aster Health has funded a twelve-week pilot to reduce the time required to correct
inpatient medical-necessity denials. The sold brief describes automatic corrected-
claim resubmission for NorthLake and Summit Health. Discovery begins after signing.
The delivery team must decide in ten business days whether a safe bounded kickoff
is possible.

## Available sources

| Source ID | Source and revision | Evidence class | Scope | Limitation |
| --- | --- | --- | --- | --- |
| S1 | SOW, revision 3, 2 Aug | Commercial commitment | Pilot scope | Written before operator observation |
| S2 | Sponsor interview, 4 Aug | Stakeholder assertion | Intended business outcome | Sponsor does not perform claim correction |
| S3 | Operator observation, cases C-104 and C-105, 5 Aug | Observed cases | NorthLake inpatient denials | Two cases do not establish frequency |

## S1 — SOW revision 3

> The pilot will classify inpatient medical-necessity denials for NorthLake and
> Summit Health, assemble supporting evidence, generate a correction, and
> automatically resubmit eligible corrected claims. The pilot will be accepted
> when average handling time improves by 30 percent and generated explanations
> meet reviewer expectations.

Additional terms:

- Delivery window: twelve weeks from kickoff.
- Named acceptance authority: Aster Revenue Cycle VP.
- No eligible-population definition, baseline window, error guardrail, or
  explanation-quality rubric is attached.
- The commercial estimate assumes 1,200 eligible denials per month across both
  payers.

## S2 — Sponsor interview note

> We should remove manual submission work. Both payer adapters already automate
> most corrections, so the AI only needs to choose the right correction and send
> it. We estimate fifteen minutes per claim today.

The sponsor is the VP of Revenue Cycle. The note records intent and estimates; it
does not include an observed case, query, measured saving, or approved policy
exception.

## S3 — Operator observation

### Case C-104: routine NorthLake denial

1. The workbench received denial code CO-50 at 09:14.
2. Billing specialist Maya Chen opened the claim, encounter note, payer rule, and
   facility profile.
3. Maya selected the missing medical-necessity attachment and changed the proposed
   correction reason.
4. Maya approved and submitted at 09:41.
5. The claims system recorded `accepted_for_processing` at 09:43.

### Case C-105: modifier exception

1. The workbench received denial code CO-97 at 10:06.
2. The NorthLake adapter proposed removing modifier 25.
3. The encounter note documented a separately identifiable same-day evaluation.
4. Maya restored modifier 25, attached the note, and recorded “NorthLake exception”
   in the workbench.
5. Maya approved and submitted at 10:38; readback was unavailable until 10:52.

Operator statements recorded after the cases:

> We check the encounter note before every modifier correction. The adapter was
> copied from Summit years ago, and its default is wrong for this NorthLake case.

> I have never seen a corrected claim submitted without a billing specialist
> approving it in this workbench.

The first statement's frequency claim is an assertion unless measured. The second
reports Maya's experience, not a complete audit of all submissions.

Complete Mission 1 before opening the
[Mission 2 evidence](https://www.lumyn.cc/resources/claims-denial-stage-2/).