Staged case evidence
Claims-Denial Case — Mission 1 Evidence
Claims-Denial Case — Mission 1 Evidence: a bounded synthetic evidence reveal for the Lumyn FDE School claims-denial practice case.
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
- The workbench received denial code CO-50 at 09:14.
- Billing specialist Maya Chen opened the claim, encounter note, payer rule, and facility profile.
- Maya selected the missing medical-necessity attachment and changed the proposed correction reason.
- Maya approved and submitted at 09:41.
- The claims system recorded
accepted_for_processingat 09:43.
Case C-105: modifier exception
- The workbench received denial code CO-97 at 10:06.
- The NorthLake adapter proposed removing modifier 25.
- The encounter note documented a separately identifiable same-day evaluation.
- Maya restored modifier 25, attached the note, and recorded “NorthLake exception” in the workbench.
- 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.