Workflows/Complex Claim Adjudication — M-8832
18 decisions · 17 governed
3
MS

Complex Claim Adjudication — Member M-8832, Cardiac Rehab Extension

In ProgressStep 4 of 6
Started 9 Aug 2026, 09:15 · Est. completion 09 Aug, 11:30 · Triggered by claims reviewer referral
MS
Maria Santos, Claims Reviewer
Process Timeline
Member Record Assembly
09:15 – 09:16 (52s)
Retrieved member demographics, enrollment history, clinical records, and prior claims from 3 systems
12 records from 3 systems
Auto-verified
Clinical History Analysis
09:16 – 09:19 (2m 41s)
Analyzed surgical history, rehabilitation progress, functional assessments, comorbidity profile
8 clinical documents
Auto-verified
Functional capacity 5.2 METs — below 7.0 target for age and procedure
Guideline Matching
09:19 – 09:22 (2m 58s)
Matched clinical profile against ACC/AHA 2026 cardiac rehab guidelines and AACVPR risk stratification
2 guideline sources
Auto-verified
Guidelines support extension when target METs not achieved with active comorbidities
Benefit Verification & Policy Cross-Reference
09:22 – ongoing
Verifying requested service against plan benefit structure, checking prior authorizations and benefit limits
Reviewing extension provision in Plan Document Section 4.2.3.b
Clinical review checkpoint
Determination Assembly
Assemble determination letter with clinical rationale, evidence citations, and benefit references
Reviewer sign-off required
Member Communication Generation
Generate member-facing explanation of benefits and determination letter
Compliance review for regulatory language

Step 4: Benefit Verification & Policy Cross-Reference

In Progress
What the agent is doing
Cross-referencing the requested 12-session extension against plan benefit limits, prior authorization requirements, and clinical review criteria.
Verification Progress
Plan Document Section 4.2.3 — Standard 36-session benefit confirmed exhausted
Section 4.2.3.b — Extension provision exists (up to 24 additional sessions)
Clinical review threshold — Extension requires documented medical necessity (pending reviewer confirmation)
Prior authorization PA-2026-MH-8832 — Original on file, extension requires new PA
Governance Checkpoint
Clinical Review Required
Extension beyond standard benefit requires clinical reviewer confirmation that medical necessity criteria are met per plan definition (Section 1.4)
Evidence for This Step
Plan Document 2026, Section 4.2.3 — Benefits Schedule
Prior Auth PA-2026-MH-8832 — Original authorization
ACC/AHA Cardiac Rehab Guidelines 2026 — Section 7.3
Dr. Robert Kim progress notes — 28 Jul 2026
Four Pillars
Meaning: Medical necessity per Plan Section 1.4 cross-referenced with ACC/AHA criteria
Process: Step 4 of 6 per adjudication workflow CL-WF-002
Evidence: 4 sources verified, clinical review pending
Record: EB-2026-0809-HP-02341-S4 · 09:22:08Z