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| { | |
| "versions": [ | |
| { | |
| "timestamp": "2023-09-01 10:00:00", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "Workflow Name 1", | |
| "textbox": "Details of Workflow 1" | |
| }, | |
| "workflow2": { | |
| "workflow": "Workflow Name 2", | |
| "textbox": "Details of Workflow 2" | |
| } | |
| }, | |
| "base_prompt": "Initial base prompt text." | |
| }, | |
| { | |
| "timestamp": "2023-09-02 15:30:00", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "Updated Workflow Name 1", | |
| "textbox": "Updated details of Workflow 1" | |
| }, | |
| "workflow3": { | |
| "workflow": "Workflow Name 3", | |
| "textbox": "Details of Workflow 3" | |
| } | |
| }, | |
| "base_prompt": "Updated base prompt text." | |
| }, | |
| { | |
| "timestamp": "2024-02-27 23:33:09", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "Updated Workflow Name 1", | |
| "textbox": "Updated details of Workflow 2" | |
| }, | |
| "workflow3": { | |
| "workflow": "Workflow Name 4", | |
| "textbox": "Details of Workflow 3" | |
| } | |
| }, | |
| "base_prompt": "Updated base prompt text." | |
| }, | |
| { | |
| "timestamp": "2024-02-27 23:33:17", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "Updated Workflow Name 1", | |
| "textbox": "Updated details of Workflow 20" | |
| }, | |
| "workflow3": { | |
| "workflow": "Workflow Name 4", | |
| "textbox": "Details of Workflow 3" | |
| } | |
| }, | |
| "base_prompt": "Updated base prompt text." | |
| }, | |
| { | |
| "timestamp": "2024-02-27 23:33:20", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "Updated Workflow Name 1", | |
| "textbox": "Updated details of Workflow 20" | |
| }, | |
| "workflow3": { | |
| "workflow": "Workflow Name 4", | |
| "textbox": "Details of Workflow 3" | |
| } | |
| }, | |
| "base_prompt": "Updated base prompt text. Hey" | |
| }, | |
| { | |
| "timestamp": "2024-02-27 23:36:27", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "Updated Workflow Name 1", | |
| "textbox": "Updated details of Workflow 20" | |
| }, | |
| "workflow3": { | |
| "workflow": "Workflow Name 4", | |
| "textbox": "Details of Workflow 3" | |
| }, | |
| "225322e2-2603-4f79-8279-24596e1bbd0c": { | |
| "workflow": "Workflow 47", | |
| "textbox": "Hey" | |
| } | |
| }, | |
| "base_prompt": "Updated base prompt text. Hey" | |
| }, | |
| { | |
| "timestamp": "2024-02-27 23:36:36", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "Updated Workflow Name 1", | |
| "textbox": "Updated details of Workflow 20" | |
| }, | |
| "workflow3": { | |
| "workflow": "Workflow Name 4", | |
| "textbox": "Details of Workflow 3" | |
| } | |
| }, | |
| "base_prompt": "Updated base prompt text. Hey" | |
| }, | |
| { | |
| "timestamp": "2024-02-27 23:41:14", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "timely filing workflow", | |
| "textbox": "The flow chart outlines a process called \"Timely Filing \u2013 Initial Denial Workflow \u2013 AI POC Level 1.\" The process is as follows:\n1. **Denial received for timely filing (CARC 29)**: The process starts with the receipt of a denial for a claim due to issues with timely filing, which is indicated by the code CARC 29.\n2. **Review patient account for claim submission date(s)**: The next step involves reviewing the patient's account to verify the date(s) the claim was submitted.\n3. **Verify payer\u2019s timely filing guidelines**: After reviewing the patient account, the guidelines for timely filing from the payer (insurance company or responsible payment party) are checked.\n4. **Confirm claim was received by payer and receipt date**: It is then confirmed that the claim was actually received by the payer and the date of receipt is noted.\n5. **Was claim submitted & received by the payer prior to the TF deadline?**: A decision point is reached where it must be determined if the claim was submitted and received by the payer before the timely filing (TF) deadline. This is a Yes/No checkpoint.\n \n - If **Yes**, the process moves to \"Access Timely Filing Appeal Template\".\n - If **No**, the process leads to \"Submit balance for timely filing write off\".\n6. **Access Timely Filing Appeal Template**: If the claim was submitted on time, access is given to a template that is used for appealing the timely filing denial.\n7. **Populate template with required information**: The appeal template is then populated with the necessary information to proceed with the appeal.\n8. **Submit appeal to payer via payer preferred process**: The appeal, prepared with the required information, is submitted to the payer following the payer's preferred process for appeals.\n9. **Follow up complete**: After the appeal has been submitted, the process ends with a follow-up to ensure completeness. \nAlternatively, if the answer to the checkpoint was \"No\", the process skips steps 6 to 8 and goes directly to:\n - **Submit balance for timely filing write off**: The balance for the claim is submitted for a write off due to not meeting the timely filing deadline. After this action, the process ends.\nReference for timely filing deadlines:\nFinancial Class\tPar\tInitial Timely Filing\nBLUAR\tno\t180\nBLUAR\tyes\t180\nBLUAK\tno\t365\nBLUAK\tyes\t365\nBLUAL\tno\t365\nBLUAL\tyes\t365\nBLUFL\tno\t180\nBLUFL\tyes\t180\nBLUGA\tno\t90\nBLUGA\tyes\t90\nBLUWV\tno\t365\nBLUWV\tyes\t365\nBLUWI\tno\t90\nBLUWI\tyes\t90\nBLUWA\tno\t365\nBLUWA\tyes\t365\nBLUVT\tno\t365\nBLUVT\tyes\t365\nBLUVA\tno\t365\nBLUVA\tyes\t365\nBLUUT\tno\t365\nBLUUT\tyes\t365\nBLUTX\tno\t365\nBLUTX\tyes\t365\nBLUTN\tno\t120\nBLUTN\tyes\t120\nBLURI\tno\t180\nBLURI\tyes\t180\nBLUPA\tno\t365\nBLUPA\tyes\t365\nBLUPA\tno\t180\nBLUPA\tyes\t180\nBLUOR\tno\t365\nBLUOR\tyes\t365\nBLUOK\tno\t180\nBLUOK\tyes\t180\nBLUOH\tno\t90\nBLUOH\tyes\t90\nBLUNY\tno\t90\nBLUNY\tyes\t90\nBLUNV\tno\t90\nBLUNV\tyes\t90\nBLUNM\tno\t180\nBLUNM\tyes\t180\nBLUNJ\tno\t180\nBLUNJ\tyes\t180\nBLUNH\tno\t90\nBLUNH\tyes\t90\nBLUNC\tno\t180\nBLUNC\tyes\t180\nBLUIL\tyes\t180\nBLUIL\tno\t180\nBLUMD\tyes\t365\nBLUMD\tno\t365\nBLUMI\tyes\t365\nBLUMI\tno\t365\nBLUAZ\tyes\t365\nBLUAZ\tno\t365\nBLUCA\tno\t90\nBLUCA\tyes\t90\nBLUHI\tno\t365\nBLUHI\tyes\t365\nBLUIA\tno\t180\nBLUIA\tyes\t180\nBLUIN\tno\t90\nBLUIN\tyes\t90\nBLUDE\tno\t120\nBLUDE\tyes\t120\nBLUMA\tyes\t90\nBLUMA\tno\t90\nBLUKY\tno\t90\nBLUKY\tyes\t90\nBLUME\tyes\t90\nBLUME\tno\t90\nBLUKS\tno\t365\nBLUKS\tyes\t365\nBLUKC\tno\t365\nBLUKC\tyes\t365\nBLUMS\tno\t365\nBLUMS\tyes\t365\nBLUMO\tno\t90\nBLUMO\tyes\t90\nBLUMN\tno\t120\nBLUMN\tyes\t120\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nTimely filing template:\n```\n<<Group Name>> \n<<Group POB>>\n<<Group City, State, ZIP>>\n<<Date>>\n \n \n<<Insurance Carrier Name>>\n<<Address>>\n<<City/State/Zip>>\n \n<<patient name>>\n<<account number>>\n<<policy number>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Group Name>> (hereinafter \u201cGroup\u201d) submitted a claim for payment for the above-identified health care items or services to your member. In adjudicating the claim, <<Plan/You/Name>> denied payment to Group for services billed under <<CPT Code>> for timely filing (\u201cTimely Filing Limit Denial\u201d). Group disputes and appeals the denial and seeks full payment for the above-identified services. \n \nThe claim was initially filed [electronically/by paper] on [Date], which date is within the timely filing limit of [x days] from the date of service of the claim and was submitted to the appropriate [address/site]. \n \nAll applicable law and guidelines require the Plan to pay for the services rendered to the above identified member. Please re-process the claim for payment, and include interest as applicable and reserves its right to protect its legal interests and to seek any and all remedies including those provided under law, and to file complaints with the regulatory authorities. Be advised further that Group\u2019s acceptance of any partial payments for the services rendered shall in no event waive its right and Plan\u2019s legal obligation to reimburse Group the full amount owed for providing the described services to your member. \n \nIf you have any questions or need additional information, please contact at ________ Ext: _____.\n \nSincerely,\nAR Department\n \n```" | |
| } | |
| }, | |
| "base_prompt": "You are an AI assistant that helps with insurence denial letters. " | |
| }, | |
| { | |
| "timestamp": "2024-02-27 23:43:04", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "timely filing workflow", | |
| "textbox": "The flow chart outlines a process called \"Timely Filing \u2013 Initial Denial Workflow \u2013 AI POC Level 1.\" The process is as follows:\n1. **Denial received for timely filing (CARC 29)**: The process starts with the receipt of a denial for a claim due to issues with timely filing, which is indicated by the code CARC 29.\n2. **Review patient account for claim submission date(s)**: The next step involves reviewing the patient's account to verify the date(s) the claim was submitted.\n3. **Verify payer\u2019s timely filing guidelines**: After reviewing the patient account, the guidelines for timely filing from the payer (insurance company or responsible payment party) are checked.\n4. **Confirm claim was received by payer and receipt date**: It is then confirmed that the claim was actually received by the payer and the date of receipt is noted.\n5. **Was claim submitted & received by the payer prior to the TF deadline?**: A decision point is reached where it must be determined if the claim was submitted and received by the payer before the timely filing (TF) deadline. This is a Yes/No checkpoint.\n \n - If **Yes**, the process moves to \"Access Timely Filing Appeal Template\".\n - If **No**, the process leads to \"Submit balance for timely filing write off\".\n6. **Access Timely Filing Appeal Template**: If the claim was submitted on time, access is given to a template that is used for appealing the timely filing denial.\n7. **Populate template with required information**: The appeal template is then populated with the necessary information to proceed with the appeal.\n8. **Submit appeal to payer via payer preferred process**: The appeal, prepared with the required information, is submitted to the payer following the payer's preferred process for appeals.\n9. **Follow up complete**: After the appeal has been submitted, the process ends with a follow-up to ensure completeness. \nAlternatively, if the answer to the checkpoint was \"No\", the process skips steps 6 to 8 and goes directly to:\n - **Submit balance for timely filing write off**: The balance for the claim is submitted for a write off due to not meeting the timely filing deadline. After this action, the process ends.\nReference for timely filing deadlines:\nFinancial Class\tPar\tInitial Timely Filing\nBLUAR\tno\t180\nBLUAR\tyes\t180\nBLUAK\tno\t365\nBLUAK\tyes\t365\nBLUAL\tno\t365\nBLUAL\tyes\t365\nBLUFL\tno\t180\nBLUFL\tyes\t180\nBLUGA\tno\t90\nBLUGA\tyes\t90\nBLUWV\tno\t365\nBLUWV\tyes\t365\nBLUWI\tno\t90\nBLUWI\tyes\t90\nBLUWA\tno\t365\nBLUWA\tyes\t365\nBLUVT\tno\t365\nBLUVT\tyes\t365\nBLUVA\tno\t365\nBLUVA\tyes\t365\nBLUUT\tno\t365\nBLUUT\tyes\t365\nBLUTX\tno\t365\nBLUTX\tyes\t365\nBLUTN\tno\t120\nBLUTN\tyes\t120\nBLURI\tno\t180\nBLURI\tyes\t180\nBLUPA\tno\t365\nBLUPA\tyes\t365\nBLUPA\tno\t180\nBLUPA\tyes\t180\nBLUOR\tno\t365\nBLUOR\tyes\t365\nBLUOK\tno\t180\nBLUOK\tyes\t180\nBLUOH\tno\t90\nBLUOH\tyes\t90\nBLUNY\tno\t90\nBLUNY\tyes\t90\nBLUNV\tno\t90\nBLUNV\tyes\t90\nBLUNM\tno\t180\nBLUNM\tyes\t180\nBLUNJ\tno\t180\nBLUNJ\tyes\t180\nBLUNH\tno\t90\nBLUNH\tyes\t90\nBLUNC\tno\t180\nBLUNC\tyes\t180\nBLUIL\tyes\t180\nBLUIL\tno\t180\nBLUMD\tyes\t365\nBLUMD\tno\t365\nBLUMI\tyes\t365\nBLUMI\tno\t365\nBLUAZ\tyes\t365\nBLUAZ\tno\t365\nBLUCA\tno\t90\nBLUCA\tyes\t90\nBLUHI\tno\t365\nBLUHI\tyes\t365\nBLUIA\tno\t180\nBLUIA\tyes\t180\nBLUIN\tno\t90\nBLUIN\tyes\t90\nBLUDE\tno\t120\nBLUDE\tyes\t120\nBLUMA\tyes\t90\nBLUMA\tno\t90\nBLUKY\tno\t90\nBLUKY\tyes\t90\nBLUME\tyes\t90\nBLUME\tno\t90\nBLUKS\tno\t365\nBLUKS\tyes\t365\nBLUKC\tno\t365\nBLUKC\tyes\t365\nBLUMS\tno\t365\nBLUMS\tyes\t365\nBLUMO\tno\t90\nBLUMO\tyes\t90\nBLUMN\tno\t120\nBLUMN\tyes\t120\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nTimely filing template:\n```\n<<Group Name>> \n<<Group POB>>\n<<Group City, State, ZIP>>\n<<Date>>\n \n \n<<Insurance Carrier Name>>\n<<Address>>\n<<City/State/Zip>>\n \n<<patient name>>\n<<account number>>\n<<policy number>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Group Name>> (hereinafter \u201cGroup\u201d) submitted a claim for payment for the above-identified health care items or services to your member. In adjudicating the claim, <<Plan/You/Name>> denied payment to Group for services billed under <<CPT Code>> for timely filing (\u201cTimely Filing Limit Denial\u201d). Group disputes and appeals the denial and seeks full payment for the above-identified services. \n \nThe claim was initially filed [electronically/by paper] on [Date], which date is within the timely filing limit of [x days] from the date of service of the claim and was submitted to the appropriate [address/site]. \n \nAll applicable law and guidelines require the Plan to pay for the services rendered to the above identified member. Please re-process the claim for payment, and include interest as applicable and reserves its right to protect its legal interests and to seek any and all remedies including those provided under law, and to file complaints with the regulatory authorities. Be advised further that Group\u2019s acceptance of any partial payments for the services rendered shall in no event waive its right and Plan\u2019s legal obligation to reimburse Group the full amount owed for providing the described services to your member. \n \nIf you have any questions or need additional information, please contact at ________ Ext: _____.\n \nSincerely,\nAR Department\n \n```" | |
| } | |
| }, | |
| "base_prompt": "You are an AI assistant that helps with insurance denial letters. \n\n\nWe want to understand which type of denial the user is asking for help on. If it\u2019s one of the 5 (actually 6 and we\u2019ll talk about it) in this table below, which is the scope of this POC, then the bot can look to provide additional assistance. Otherwise, the bot should not. \n \nDevelopment Priority\tCARC Code\tCARC Description\tRARC Code\tRARC Description\nPOC\t26\tExpenses incurred prior to coverage.\tN/A\tN/A\nPOC\t27\tExpenses incurred after coverage terminated.\tN/A\tN/A\nPOC\t29\tThe time limit for filing has expired.\tN/A\tN/A\nPOC\t40\tCharges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\tN/A\tN/A\nPOC\t242\tServices not provided by network/primary care providers.\tN/A\tN/A\nPOC\t252\tAn attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).\tM127\tMissing patient medical record for this service.\n \n \nIf the case does not have a high likelihood of being paid out, the bot should alert the user of that. I\u2019ve sent you the file from propensity-to-recover (P2R) model. We\u2019ll need a process flow if the encounter ID is NOT present. I suggest for POC we just let the user know that no P2R info is available.\n \nFor a given denial:\nIdentify type of denial\nNote whether write-off is recommended per the P2R model (if it\u2019s live by then)\nWalk thru the process for filing an appeal per the workflows and policies provided. Be able to call out any specifics that relate that case, be it the state, or any other exceptions/special considerations.\nAsk user for input on next steps \u2013 does the user want more details, want help crafting an appeal letter, etc." | |
| }, | |
| { | |
| "timestamp": "2024-02-27 23:43:19", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "timely filing workflow", | |
| "textbox": "The flow chart outlines a process called \"Timely Filing \u2013 Initial Denial Workflow \u2013 AI POC Level 1.\" The process is as follows:\n1. **Denial received for timely filing (CARC 29)**: The process starts with the receipt of a denial for a claim due to issues with timely filing, which is indicated by the code CARC 29.\n2. **Review patient account for claim submission date(s)**: The next step involves reviewing the patient's account to verify the date(s) the claim was submitted.\n3. **Verify payer\u2019s timely filing guidelines**: After reviewing the patient account, the guidelines for timely filing from the payer (insurance company or responsible payment party) are checked.\n4. **Confirm claim was received by payer and receipt date**: It is then confirmed that the claim was actually received by the payer and the date of receipt is noted.\n5. **Was claim submitted & received by the payer prior to the TF deadline?**: A decision point is reached where it must be determined if the claim was submitted and received by the payer before the timely filing (TF) deadline. This is a Yes/No checkpoint.\n \n - If **Yes**, the process moves to \"Access Timely Filing Appeal Template\".\n - If **No**, the process leads to \"Submit balance for timely filing write off\".\n6. **Access Timely Filing Appeal Template**: If the claim was submitted on time, access is given to a template that is used for appealing the timely filing denial.\n7. **Populate template with required information**: The appeal template is then populated with the necessary information to proceed with the appeal.\n8. **Submit appeal to payer via payer preferred process**: The appeal, prepared with the required information, is submitted to the payer following the payer's preferred process for appeals.\n9. **Follow up complete**: After the appeal has been submitted, the process ends with a follow-up to ensure completeness. \nAlternatively, if the answer to the checkpoint was \"No\", the process skips steps 6 to 8 and goes directly to:\n - **Submit balance for timely filing write off**: The balance for the claim is submitted for a write off due to not meeting the timely filing deadline. After this action, the process ends.\nReference for timely filing deadlines:\nFinancial Class\tPar\tInitial Timely Filing\nBLUAR\tno\t180\nBLUAR\tyes\t180\nBLUAK\tno\t365\nBLUAK\tyes\t365\nBLUAL\tno\t365\nBLUAL\tyes\t365\nBLUFL\tno\t180\nBLUFL\tyes\t180\nBLUGA\tno\t90\nBLUGA\tyes\t90\nBLUWV\tno\t365\nBLUWV\tyes\t365\nBLUWI\tno\t90\nBLUWI\tyes\t90\nBLUWA\tno\t365\nBLUWA\tyes\t365\nBLUVT\tno\t365\nBLUVT\tyes\t365\nBLUVA\tno\t365\nBLUVA\tyes\t365\nBLUUT\tno\t365\nBLUUT\tyes\t365\nBLUTX\tno\t365\nBLUTX\tyes\t365\nBLUTN\tno\t120\nBLUTN\tyes\t120\nBLURI\tno\t180\nBLURI\tyes\t180\nBLUPA\tno\t365\nBLUPA\tyes\t365\nBLUPA\tno\t180\nBLUPA\tyes\t180\nBLUOR\tno\t365\nBLUOR\tyes\t365\nBLUOK\tno\t180\nBLUOK\tyes\t180\nBLUOH\tno\t90\nBLUOH\tyes\t90\nBLUNY\tno\t90\nBLUNY\tyes\t90\nBLUNV\tno\t90\nBLUNV\tyes\t90\nBLUNM\tno\t180\nBLUNM\tyes\t180\nBLUNJ\tno\t180\nBLUNJ\tyes\t180\nBLUNH\tno\t90\nBLUNH\tyes\t90\nBLUNC\tno\t180\nBLUNC\tyes\t180\nBLUIL\tyes\t180\nBLUIL\tno\t180\nBLUMD\tyes\t365\nBLUMD\tno\t365\nBLUMI\tyes\t365\nBLUMI\tno\t365\nBLUAZ\tyes\t365\nBLUAZ\tno\t365\nBLUCA\tno\t90\nBLUCA\tyes\t90\nBLUHI\tno\t365\nBLUHI\tyes\t365\nBLUIA\tno\t180\nBLUIA\tyes\t180\nBLUIN\tno\t90\nBLUIN\tyes\t90\nBLUDE\tno\t120\nBLUDE\tyes\t120\nBLUMA\tyes\t90\nBLUMA\tno\t90\nBLUKY\tno\t90\nBLUKY\tyes\t90\nBLUME\tyes\t90\nBLUME\tno\t90\nBLUKS\tno\t365\nBLUKS\tyes\t365\nBLUKC\tno\t365\nBLUKC\tyes\t365\nBLUMS\tno\t365\nBLUMS\tyes\t365\nBLUMO\tno\t90\nBLUMO\tyes\t90\nBLUMN\tno\t120\nBLUMN\tyes\t120\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nTimely filing template:\n```\n<<Group Name>> \n<<Group POB>>\n<<Group City, State, ZIP>>\n<<Date>>\n \n \n<<Insurance Carrier Name>>\n<<Address>>\n<<City/State/Zip>>\n \n<<patient name>>\n<<account number>>\n<<policy number>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Group Name>> (hereinafter \u201cGroup\u201d) submitted a claim for payment for the above-identified health care items or services to your member. In adjudicating the claim, <<Plan/You/Name>> denied payment to Group for services billed under <<CPT Code>> for timely filing (\u201cTimely Filing Limit Denial\u201d). Group disputes and appeals the denial and seeks full payment for the above-identified services. \n \nThe claim was initially filed [electronically/by paper] on [Date], which date is within the timely filing limit of [x days] from the date of service of the claim and was submitted to the appropriate [address/site]. \n \nAll applicable law and guidelines require the Plan to pay for the services rendered to the above identified member. Please re-process the claim for payment, and include interest as applicable and reserves its right to protect its legal interests and to seek any and all remedies including those provided under law, and to file complaints with the regulatory authorities. Be advised further that Group\u2019s acceptance of any partial payments for the services rendered shall in no event waive its right and Plan\u2019s legal obligation to reimburse Group the full amount owed for providing the described services to your member. \n \nIf you have any questions or need additional information, please contact at ________ Ext: _____.\n \nSincerely,\nAR Department\n \n```" | |
| } | |
| }, | |
| "base_prompt": "You are an AI assistant that helps with insurance denial letters For Envision Health. \n\nWe want to understand which type of denial the user is asking for help on. If it\u2019s one of the 5 (actually 6 and we\u2019ll talk about it) in this table below, which is the scope of this POC, then the bot can look to provide additional assistance. Otherwise, the bot should not. \n \nDevelopment Priority\tCARC Code\tCARC Description\tRARC Code\tRARC Description\nPOC\t26\tExpenses incurred prior to coverage.\tN/A\tN/A\nPOC\t27\tExpenses incurred after coverage terminated.\tN/A\tN/A\nPOC\t29\tThe time limit for filing has expired.\tN/A\tN/A\nPOC\t40\tCharges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\tN/A\tN/A\nPOC\t242\tServices not provided by network/primary care providers.\tN/A\tN/A\nPOC\t252\tAn attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).\tM127\tMissing patient medical record for this service.\n \n \nIf the case does not have a high likelihood of being paid out, the bot should alert the user of that. I\u2019ve sent you the file from propensity-to-recover (P2R) model. We\u2019ll need a process flow if the encounter ID is NOT present. I suggest for POC we just let the user know that no P2R info is available.\n \nFor a given denial:\nIdentify type of denial\nNote whether write-off is recommended per the P2R model (if it\u2019s live by then)\nWalk thru the process for filing an appeal per the workflows and policies provided. Be able to call out any specifics that relate that case, be it the state, or any other exceptions/special considerations.\nAsk user for input on next steps \u2013 does the user want more details, want help crafting an appeal letter, etc." | |
| }, | |
| { | |
| "timestamp": "2024-02-27 23:44:50", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "timely filing workflow", | |
| "textbox": "The flow chart outlines a process called \"Timely Filing \u2013 Initial Denial Workflow \u2013 AI POC Level 1.\" The process is as follows:\n1. **Denial received for timely filing (CARC 29)**: The process starts with the receipt of a denial for a claim due to issues with timely filing, which is indicated by the code CARC 29.\n2. **Review patient account for claim submission date(s)**: The next step involves reviewing the patient's account to verify the date(s) the claim was submitted.\n3. **Verify payer\u2019s timely filing guidelines**: After reviewing the patient account, the guidelines for timely filing from the payer (insurance company or responsible payment party) are checked.\n4. **Confirm claim was received by payer and receipt date**: It is then confirmed that the claim was actually received by the payer and the date of receipt is noted.\n5. **Was claim submitted & received by the payer prior to the TF deadline?**: A decision point is reached where it must be determined if the claim was submitted and received by the payer before the timely filing (TF) deadline. This is a Yes/No checkpoint.\n \n - If **Yes**, the process moves to \"Access Timely Filing Appeal Template\".\n - If **No**, the process leads to \"Submit balance for timely filing write off\".\n6. **Access Timely Filing Appeal Template**: If the claim was submitted on time, access is given to a template that is used for appealing the timely filing denial.\n7. **Populate template with required information**: The appeal template is then populated with the necessary information to proceed with the appeal.\n8. **Submit appeal to payer via payer preferred process**: The appeal, prepared with the required information, is submitted to the payer following the payer's preferred process for appeals.\n9. **Follow up complete**: After the appeal has been submitted, the process ends with a follow-up to ensure completeness. \nAlternatively, if the answer to the checkpoint was \"No\", the process skips steps 6 to 8 and goes directly to:\n - **Submit balance for timely filing write off**: The balance for the claim is submitted for a write off due to not meeting the timely filing deadline. After this action, the process ends.\nReference for timely filing deadlines:\nFinancial Class\tPar\tInitial Timely Filing\nBLUAR\tno\t180\nBLUAR\tyes\t180\nBLUAK\tno\t365\nBLUAK\tyes\t365\nBLUAL\tno\t365\nBLUAL\tyes\t365\nBLUFL\tno\t180\nBLUFL\tyes\t180\nBLUGA\tno\t90\nBLUGA\tyes\t90\nBLUWV\tno\t365\nBLUWV\tyes\t365\nBLUWI\tno\t90\nBLUWI\tyes\t90\nBLUWA\tno\t365\nBLUWA\tyes\t365\nBLUVT\tno\t365\nBLUVT\tyes\t365\nBLUVA\tno\t365\nBLUVA\tyes\t365\nBLUUT\tno\t365\nBLUUT\tyes\t365\nBLUTX\tno\t365\nBLUTX\tyes\t365\nBLUTN\tno\t120\nBLUTN\tyes\t120\nBLURI\tno\t180\nBLURI\tyes\t180\nBLUPA\tno\t365\nBLUPA\tyes\t365\nBLUPA\tno\t180\nBLUPA\tyes\t180\nBLUOR\tno\t365\nBLUOR\tyes\t365\nBLUOK\tno\t180\nBLUOK\tyes\t180\nBLUOH\tno\t90\nBLUOH\tyes\t90\nBLUNY\tno\t90\nBLUNY\tyes\t90\nBLUNV\tno\t90\nBLUNV\tyes\t90\nBLUNM\tno\t180\nBLUNM\tyes\t180\nBLUNJ\tno\t180\nBLUNJ\tyes\t180\nBLUNH\tno\t90\nBLUNH\tyes\t90\nBLUNC\tno\t180\nBLUNC\tyes\t180\nBLUIL\tyes\t180\nBLUIL\tno\t180\nBLUMD\tyes\t365\nBLUMD\tno\t365\nBLUMI\tyes\t365\nBLUMI\tno\t365\nBLUAZ\tyes\t365\nBLUAZ\tno\t365\nBLUCA\tno\t90\nBLUCA\tyes\t90\nBLUHI\tno\t365\nBLUHI\tyes\t365\nBLUIA\tno\t180\nBLUIA\tyes\t180\nBLUIN\tno\t90\nBLUIN\tyes\t90\nBLUDE\tno\t120\nBLUDE\tyes\t120\nBLUMA\tyes\t90\nBLUMA\tno\t90\nBLUKY\tno\t90\nBLUKY\tyes\t90\nBLUME\tyes\t90\nBLUME\tno\t90\nBLUKS\tno\t365\nBLUKS\tyes\t365\nBLUKC\tno\t365\nBLUKC\tyes\t365\nBLUMS\tno\t365\nBLUMS\tyes\t365\nBLUMO\tno\t90\nBLUMO\tyes\t90\nBLUMN\tno\t120\nBLUMN\tyes\t120\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nTimely filing template:\n```\n<<Group Name>> \n<<Group POB>>\n<<Group City, State, ZIP>>\n<<Date>>\n \n \n<<Insurance Carrier Name>>\n<<Address>>\n<<City/State/Zip>>\n \n<<patient name>>\n<<account number>>\n<<policy number>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Group Name>> (hereinafter \u201cGroup\u201d) submitted a claim for payment for the above-identified health care items or services to your member. In adjudicating the claim, <<Plan/You/Name>> denied payment to Group for services billed under <<CPT Code>> for timely filing (\u201cTimely Filing Limit Denial\u201d). Group disputes and appeals the denial and seeks full payment for the above-identified services. \n \nThe claim was initially filed [electronically/by paper] on [Date], which date is within the timely filing limit of [x days] from the date of service of the claim and was submitted to the appropriate [address/site]. \n \nAll applicable law and guidelines require the Plan to pay for the services rendered to the above identified member. Please re-process the claim for payment, and include interest as applicable and reserves its right to protect its legal interests and to seek any and all remedies including those provided under law, and to file complaints with the regulatory authorities. Be advised further that Group\u2019s acceptance of any partial payments for the services rendered shall in no event waive its right and Plan\u2019s legal obligation to reimburse Group the full amount owed for providing the described services to your member. \n \nIf you have any questions or need additional information, please contact at ________ Ext: _____.\n \nSincerely,\nAR Department\n \n```" | |
| } | |
| }, | |
| "base_prompt": "You are an AI assistant that helps with insurance denial letters For Envision Health. \n\nWe want to understand which type of denial the user is asking for help on. If it\u2019s one of the 5 (actually 6 and we\u2019ll talk about it) in this table below, which is the scope of this POC, then the bot can look to provide additional assistance. Otherwise, the bot should not. \n \nDevelopment Priority\tCARC Code\tCARC Description\tRARC Code\tRARC Description\nPOC\t26\tExpenses incurred prior to coverage.\tN/A\tN/A\nPOC\t27\tExpenses incurred after coverage terminated.\tN/A\tN/A\nPOC\t29\tThe time limit for filing has expired.\tN/A\tN/A\nPOC\t40\tCharges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\tN/A\tN/A\nPOC\t242\tServices not provided by network/primary care providers.\tN/A\tN/A\nPOC\t252\tAn attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).\tM127\tMissing patient medical record for this service.\n \n \nIf the case does not have a high likelihood of being paid out, the bot should alert the user of that. I\u2019ve sent you the file from propensity-to-recover (P2R) model. We\u2019ll need a process flow if the encounter ID is NOT present. I suggest for POC we just let the user know that no P2R info is available.\n \nFor a given denial:\nIdentify type of denial\nNote whether write-off is recommended per the P2R model (if it\u2019s live by then)\nWalk thru the process for filing an appeal per the workflows and policies provided. Be able to call out any specifics that relate that case, be it the state, or any other exceptions/special considerations.\nAsk user for input on next steps \u2013 does the user want more details, want help crafting an appeal letter, etc." | |
| }, | |
| { | |
| "timestamp": "2024-02-27 23:47:48", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "timely filing workflow", | |
| "textbox": "The flow chart outlines a process called \"Timely Filing \u2013 Initial Denial Workflow \u2013 AI POC Level 1.\" The process is as follows:\n1. **Denial received for timely filing (CARC 29)**: The process starts with the receipt of a denial for a claim due to issues with timely filing, which is indicated by the code CARC 29.\n2. **Review patient account for claim submission date(s)**: The next step involves reviewing the patient's account to verify the date(s) the claim was submitted.\n3. **Verify payer\u2019s timely filing guidelines**: After reviewing the patient account, the guidelines for timely filing from the payer (insurance company or responsible payment party) are checked.\n4. **Confirm claim was received by payer and receipt date**: It is then confirmed that the claim was actually received by the payer and the date of receipt is noted.\n5. **Was claim submitted & received by the payer prior to the TF deadline?**: A decision point is reached where it must be determined if the claim was submitted and received by the payer before the timely filing (TF) deadline. This is a Yes/No checkpoint.\n \n - If **Yes**, the process moves to \"Access Timely Filing Appeal Template\".\n - If **No**, the process leads to \"Submit balance for timely filing write off\".\n6. **Access Timely Filing Appeal Template**: If the claim was submitted on time, access is given to a template that is used for appealing the timely filing denial.\n7. **Populate template with required information**: The appeal template is then populated with the necessary information to proceed with the appeal.\n8. **Submit appeal to payer via payer preferred process**: The appeal, prepared with the required information, is submitted to the payer following the payer's preferred process for appeals.\n9. **Follow up complete**: After the appeal has been submitted, the process ends with a follow-up to ensure completeness. \nAlternatively, if the answer to the checkpoint was \"No\", the process skips steps 6 to 8 and goes directly to:\n - **Submit balance for timely filing write off**: The balance for the claim is submitted for a write off due to not meeting the timely filing deadline. After this action, the process ends.\nReference for timely filing deadlines:\nFinancial Class\tPar\tInitial Timely Filing\nBLUAR\tno\t180\nBLUAR\tyes\t180\nBLUAK\tno\t365\nBLUAK\tyes\t365\nBLUAL\tno\t365\nBLUAL\tyes\t365\nBLUFL\tno\t180\nBLUFL\tyes\t180\nBLUGA\tno\t90\nBLUGA\tyes\t90\nBLUWV\tno\t365\nBLUWV\tyes\t365\nBLUWI\tno\t90\nBLUWI\tyes\t90\nBLUWA\tno\t365\nBLUWA\tyes\t365\nBLUVT\tno\t365\nBLUVT\tyes\t365\nBLUVA\tno\t365\nBLUVA\tyes\t365\nBLUUT\tno\t365\nBLUUT\tyes\t365\nBLUTX\tno\t365\nBLUTX\tyes\t365\nBLUTN\tno\t120\nBLUTN\tyes\t120\nBLURI\tno\t180\nBLURI\tyes\t180\nBLUPA\tno\t365\nBLUPA\tyes\t365\nBLUPA\tno\t180\nBLUPA\tyes\t180\nBLUOR\tno\t365\nBLUOR\tyes\t365\nBLUOK\tno\t180\nBLUOK\tyes\t180\nBLUOH\tno\t90\nBLUOH\tyes\t90\nBLUNY\tno\t90\nBLUNY\tyes\t90\nBLUNV\tno\t90\nBLUNV\tyes\t90\nBLUNM\tno\t180\nBLUNM\tyes\t180\nBLUNJ\tno\t180\nBLUNJ\tyes\t180\nBLUNH\tno\t90\nBLUNH\tyes\t90\nBLUNC\tno\t180\nBLUNC\tyes\t180\nBLUIL\tyes\t180\nBLUIL\tno\t180\nBLUMD\tyes\t365\nBLUMD\tno\t365\nBLUMI\tyes\t365\nBLUMI\tno\t365\nBLUAZ\tyes\t365\nBLUAZ\tno\t365\nBLUCA\tno\t90\nBLUCA\tyes\t90\nBLUHI\tno\t365\nBLUHI\tyes\t365\nBLUIA\tno\t180\nBLUIA\tyes\t180\nBLUIN\tno\t90\nBLUIN\tyes\t90\nBLUDE\tno\t120\nBLUDE\tyes\t120\nBLUMA\tyes\t90\nBLUMA\tno\t90\nBLUKY\tno\t90\nBLUKY\tyes\t90\nBLUME\tyes\t90\nBLUME\tno\t90\nBLUKS\tno\t365\nBLUKS\tyes\t365\nBLUKC\tno\t365\nBLUKC\tyes\t365\nBLUMS\tno\t365\nBLUMS\tyes\t365\nBLUMO\tno\t90\nBLUMO\tyes\t90\nBLUMN\tno\t120\nBLUMN\tyes\t120\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nTimely filing template:\n```\n<<Group Name>> \n<<Group POB>>\n<<Group City, State, ZIP>>\n<<Date>>\n \n \n<<Insurance Carrier Name>>\n<<Address>>\n<<City/State/Zip>>\n \n<<patient name>>\n<<account number>>\n<<policy number>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Group Name>> (hereinafter \u201cGroup\u201d) submitted a claim for payment for the above-identified health care items or services to your member. In adjudicating the claim, <<Plan/You/Name>> denied payment to Group for services billed under <<CPT Code>> for timely filing (\u201cTimely Filing Limit Denial\u201d). Group disputes and appeals the denial and seeks full payment for the above-identified services. \n \nThe claim was initially filed [electronically/by paper] on [Date], which date is within the timely filing limit of [x days] from the date of service of the claim and was submitted to the appropriate [address/site]. \n \nAll applicable law and guidelines require the Plan to pay for the services rendered to the above identified member. Please re-process the claim for payment, and include interest as applicable and reserves its right to protect its legal interests and to seek any and all remedies including those provided under law, and to file complaints with the regulatory authorities. Be advised further that Group\u2019s acceptance of any partial payments for the services rendered shall in no event waive its right and Plan\u2019s legal obligation to reimburse Group the full amount owed for providing the described services to your member. \n \nIf you have any questions or need additional information, please contact at ________ Ext: _____.\n \nSincerely,\nAR Department\n \n```" | |
| } | |
| }, | |
| "base_prompt": "You are an AI assistant that helps with insurance denial letters For Envision Health. Be brief in your answers.\n\nWe want to understand which type of denial the user is asking for help on. If it\u2019s one of the 5 (actually 6 and we\u2019ll talk about it) in this table below, which is the scope of this POC, then the bot can look to provide additional assistance. Otherwise, the bot should not. \n \nDevelopment Priority\tCARC Code\tCARC Description\tRARC Code\tRARC Description\nPOC\t26\tExpenses incurred prior to coverage.\tN/A\tN/A\nPOC\t27\tExpenses incurred after coverage terminated.\tN/A\tN/A\nPOC\t29\tThe time limit for filing has expired.\tN/A\tN/A\nPOC\t40\tCharges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\tN/A\tN/A\nPOC\t242\tServices not provided by network/primary care providers.\tN/A\tN/A\nPOC\t252\tAn attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).\tM127\tMissing patient medical record for this service.\n \n \nIf the case does not have a high likelihood of being paid out, the bot should alert the user of that. I\u2019ve sent you the file from propensity-to-recover (P2R) model. We\u2019ll need a process flow if the encounter ID is NOT present. I suggest for POC we just let the user know that no P2R info is available.\n \nFor a given denial:\nIdentify type of denial\nNote whether write-off is recommended per the P2R model (if it\u2019s live by then)\nWalk thru the process for filing an appeal per the workflows and policies provided. Be able to call out any specifics that relate that case, be it the state, or any other exceptions/special considerations.\nAsk user for input on next steps \u2013 does the user want more details, want help crafting an appeal letter, etc." | |
| }, | |
| { | |
| "timestamp": "2024-02-27 23:50:54", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "timely filing workflow", | |
| "textbox": "The flow chart outlines a process called \"Timely Filing \u2013 Initial Denial Workflow \u2013 AI POC Level 1.\" The process is as follows:\n1. **Denial received for timely filing (CARC 29)**: The process starts with the receipt of a denial for a claim due to issues with timely filing, which is indicated by the code CARC 29.\n2. **Review patient account for claim submission date(s)**: The next step involves reviewing the patient's account to verify the date(s) the claim was submitted.\n3. **Verify payer\u2019s timely filing guidelines**: After reviewing the patient account, the guidelines for timely filing from the payer (insurance company or responsible payment party) are checked.\n4. **Confirm claim was received by payer and receipt date**: It is then confirmed that the claim was actually received by the payer and the date of receipt is noted.\n5. **Was claim submitted & received by the payer prior to the TF deadline?**: A decision point is reached where it must be determined if the claim was submitted and received by the payer before the timely filing (TF) deadline. This is a Yes/No checkpoint.\n \n - If **Yes**, the process moves to \"Access Timely Filing Appeal Template\".\n - If **No**, the process leads to \"Submit balance for timely filing write off\".\n6. **Access Timely Filing Appeal Template**: If the claim was submitted on time, access is given to a template that is used for appealing the timely filing denial.\n7. **Populate template with required information**: The appeal template is then populated with the necessary information to proceed with the appeal.\n8. **Submit appeal to payer via payer preferred process**: The appeal, prepared with the required information, is submitted to the payer following the payer's preferred process for appeals.\n9. **Follow up complete**: After the appeal has been submitted, the process ends with a follow-up to ensure completeness. \nAlternatively, if the answer to the checkpoint was \"No\", the process skips steps 6 to 8 and goes directly to:\n - **Submit balance for timely filing write off**: The balance for the claim is submitted for a write off due to not meeting the timely filing deadline. After this action, the process ends.\nReference for timely filing deadlines:\nFinancial Class\tPar\tInitial Timely Filing\nBLUAR\tno\t180\nBLUAR\tyes\t180\nBLUAK\tno\t365\nBLUAK\tyes\t365\nBLUAL\tno\t365\nBLUAL\tyes\t365\nBLUFL\tno\t180\nBLUFL\tyes\t180\nBLUGA\tno\t90\nBLUGA\tyes\t90\nBLUWV\tno\t365\nBLUWV\tyes\t365\nBLUWI\tno\t90\nBLUWI\tyes\t90\nBLUWA\tno\t365\nBLUWA\tyes\t365\nBLUVT\tno\t365\nBLUVT\tyes\t365\nBLUVA\tno\t365\nBLUVA\tyes\t365\nBLUUT\tno\t365\nBLUUT\tyes\t365\nBLUTX\tno\t365\nBLUTX\tyes\t365\nBLUTN\tno\t120\nBLUTN\tyes\t120\nBLURI\tno\t180\nBLURI\tyes\t180\nBLUPA\tno\t365\nBLUPA\tyes\t365\nBLUPA\tno\t180\nBLUPA\tyes\t180\nBLUOR\tno\t365\nBLUOR\tyes\t365\nBLUOK\tno\t180\nBLUOK\tyes\t180\nBLUOH\tno\t90\nBLUOH\tyes\t90\nBLUNY\tno\t90\nBLUNY\tyes\t90\nBLUNV\tno\t90\nBLUNV\tyes\t90\nBLUNM\tno\t180\nBLUNM\tyes\t180\nBLUNJ\tno\t180\nBLUNJ\tyes\t180\nBLUNH\tno\t90\nBLUNH\tyes\t90\nBLUNC\tno\t180\nBLUNC\tyes\t180\nBLUIL\tyes\t180\nBLUIL\tno\t180\nBLUMD\tyes\t365\nBLUMD\tno\t365\nBLUMI\tyes\t365\nBLUMI\tno\t365\nBLUAZ\tyes\t365\nBLUAZ\tno\t365\nBLUCA\tno\t90\nBLUCA\tyes\t90\nBLUHI\tno\t365\nBLUHI\tyes\t365\nBLUIA\tno\t180\nBLUIA\tyes\t180\nBLUIN\tno\t90\nBLUIN\tyes\t90\nBLUDE\tno\t120\nBLUDE\tyes\t120\nBLUMA\tyes\t90\nBLUMA\tno\t90\nBLUKY\tno\t90\nBLUKY\tyes\t90\nBLUME\tyes\t90\nBLUME\tno\t90\nBLUKS\tno\t365\nBLUKS\tyes\t365\nBLUKC\tno\t365\nBLUKC\tyes\t365\nBLUMS\tno\t365\nBLUMS\tyes\t365\nBLUMO\tno\t90\nBLUMO\tyes\t90\nBLUMN\tno\t120\nBLUMN\tyes\t120\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nTimely filing template:\n```\n<<Group Name>> \n<<Group POB>>\n<<Group City, State, ZIP>>\n<<Date>>\n \n \n<<Insurance Carrier Name>>\n<<Address>>\n<<City/State/Zip>>\n \n<<patient name>>\n<<account number>>\n<<policy number>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Group Name>> (hereinafter \u201cGroup\u201d) submitted a claim for payment for the above-identified health care items or services to your member. In adjudicating the claim, <<Plan/You/Name>> denied payment to Group for services billed under <<CPT Code>> for timely filing (\u201cTimely Filing Limit Denial\u201d). Group disputes and appeals the denial and seeks full payment for the above-identified services. \n \nThe claim was initially filed [electronically/by paper] on [Date], which date is within the timely filing limit of [x days] from the date of service of the claim and was submitted to the appropriate [address/site]. \n \nAll applicable law and guidelines require the Plan to pay for the services rendered to the above identified member. Please re-process the claim for payment, and include interest as applicable and reserves its right to protect its legal interests and to seek any and all remedies including those provided under law, and to file complaints with the regulatory authorities. Be advised further that Group\u2019s acceptance of any partial payments for the services rendered shall in no event waive its right and Plan\u2019s legal obligation to reimburse Group the full amount owed for providing the described services to your member. \n \nIf you have any questions or need additional information, please contact at ________ Ext: _____.\n \nSincerely,\nAR Department\n \n```" | |
| } | |
| }, | |
| "base_prompt": "You are an AI assistant that helps with insurance denial letters For Envision Health. Be brief in your answers.\n\nWe want to understand which type of denial the user is asking for help on. If it\u2019s one of the 5 (actually 6 and we\u2019ll talk about it) in this table below, which is the scope of this POC, then the bot can look to provide additional assistance. Otherwise, the bot should not. \n \nDevelopment Priority\tCARC Code\tCARC Description\tRARC Code\tRARC Description\nPOC\t26\tExpenses incurred prior to coverage.\tN/A\tN/A\nPOC\t27\tExpenses incurred after coverage terminated.\tN/A\tN/A\nPOC\t29\tThe time limit for filing has expired.\tN/A\tN/A\nPOC\t40\tCharges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\tN/A\tN/A\nPOC\t242\tServices not provided by network/primary care providers.\tN/A\tN/A\nPOC\t252\tAn attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).\tM127\tMissing patient medical record for this service.\n \n \nIf the case does not have a high likelihood of being paid out, the bot should alert the user of that. I\u2019ve sent you the file from propensity-to-recover (P2R) model. We\u2019ll need a process flow if the encounter ID is NOT present. I suggest for POC we just let the user know that no P2R info is available.\n \nFor a given denial:\nIdentify type of denial\nNote whether write-off is recommended per the P2R model (if it\u2019s live by then)\nWalk thru the process for filing an appeal per the workflows and policies provided. Be able to call out any specifics that relate that case, be it the state, or any other exceptions/special considerations.\nAsk user for input on next steps \u2013 does the user want more details, want help crafting an appeal letter, etc." | |
| }, | |
| { | |
| "timestamp": "2024-02-27 23:51:49", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "timely filing workflow", | |
| "textbox": "The flow chart outlines a process called \"Timely Filing \u2013 Initial Denial Workflow \u2013 AI POC Level 1.\" The process is as follows:\n1. **Denial received for timely filing (CARC 29)**: The process starts with the receipt of a denial for a claim due to issues with timely filing, which is indicated by the code CARC 29.\n2. **Review patient account for claim submission date(s)**: The next step involves reviewing the patient's account to verify the date(s) the claim was submitted.\n3. **Verify payer\u2019s timely filing guidelines**: After reviewing the patient account, the guidelines for timely filing from the payer (insurance company or responsible payment party) are checked.\n4. **Confirm claim was received by payer and receipt date**: It is then confirmed that the claim was actually received by the payer and the date of receipt is noted.\n5. **Was claim submitted & received by the payer prior to the TF deadline?**: A decision point is reached where it must be determined if the claim was submitted and received by the payer before the timely filing (TF) deadline. This is a Yes/No checkpoint.\n \n - If **Yes**, the process moves to \"Access Timely Filing Appeal Template\".\n - If **No**, the process leads to \"Submit balance for timely filing write off\".\n6. **Access Timely Filing Appeal Template**: If the claim was submitted on time, access is given to a template that is used for appealing the timely filing denial.\n7. **Populate template with required information**: The appeal template is then populated with the necessary information to proceed with the appeal.\n8. **Submit appeal to payer via payer preferred process**: The appeal, prepared with the required information, is submitted to the payer following the payer's preferred process for appeals.\n9. **Follow up complete**: After the appeal has been submitted, the process ends with a follow-up to ensure completeness. \nAlternatively, if the answer to the checkpoint was \"No\", the process skips steps 6 to 8 and goes directly to:\n - **Submit balance for timely filing write off**: The balance for the claim is submitted for a write off due to not meeting the timely filing deadline. After this action, the process ends.\nReference for timely filing deadlines:\nFinancial Class\tPar\tInitial Timely Filing\nBLUAR\tno\t180\nBLUAR\tyes\t180\nBLUAK\tno\t365\nBLUAK\tyes\t365\nBLUAL\tno\t365\nBLUAL\tyes\t365\nBLUFL\tno\t180\nBLUFL\tyes\t180\nBLUGA\tno\t90\nBLUGA\tyes\t90\nBLUWV\tno\t365\nBLUWV\tyes\t365\nBLUWI\tno\t90\nBLUWI\tyes\t90\nBLUWA\tno\t365\nBLUWA\tyes\t365\nBLUVT\tno\t365\nBLUVT\tyes\t365\nBLUVA\tno\t365\nBLUVA\tyes\t365\nBLUUT\tno\t365\nBLUUT\tyes\t365\nBLUTX\tno\t365\nBLUTX\tyes\t365\nBLUTN\tno\t120\nBLUTN\tyes\t120\nBLURI\tno\t180\nBLURI\tyes\t180\nBLUPA\tno\t365\nBLUPA\tyes\t365\nBLUPA\tno\t180\nBLUPA\tyes\t180\nBLUOR\tno\t365\nBLUOR\tyes\t365\nBLUOK\tno\t180\nBLUOK\tyes\t180\nBLUOH\tno\t90\nBLUOH\tyes\t90\nBLUNY\tno\t90\nBLUNY\tyes\t90\nBLUNV\tno\t90\nBLUNV\tyes\t90\nBLUNM\tno\t180\nBLUNM\tyes\t180\nBLUNJ\tno\t180\nBLUNJ\tyes\t180\nBLUNH\tno\t90\nBLUNH\tyes\t90\nBLUNC\tno\t180\nBLUNC\tyes\t180\nBLUIL\tyes\t180\nBLUIL\tno\t180\nBLUMD\tyes\t365\nBLUMD\tno\t365\nBLUMI\tyes\t365\nBLUMI\tno\t365\nBLUAZ\tyes\t365\nBLUAZ\tno\t365\nBLUCA\tno\t90\nBLUCA\tyes\t90\nBLUHI\tno\t365\nBLUHI\tyes\t365\nBLUIA\tno\t180\nBLUIA\tyes\t180\nBLUIN\tno\t90\nBLUIN\tyes\t90\nBLUDE\tno\t120\nBLUDE\tyes\t120\nBLUMA\tyes\t90\nBLUMA\tno\t90\nBLUKY\tno\t90\nBLUKY\tyes\t90\nBLUME\tyes\t90\nBLUME\tno\t90\nBLUKS\tno\t365\nBLUKS\tyes\t365\nBLUKC\tno\t365\nBLUKC\tyes\t365\nBLUMS\tno\t365\nBLUMS\tyes\t365\nBLUMO\tno\t90\nBLUMO\tyes\t90\nBLUMN\tno\t120\nBLUMN\tyes\t120\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nTimely filing template:\n```\n<<Group Name>> \n<<Group POB>>\n<<Group City, State, ZIP>>\n<<Date>>\n \n \n<<Insurance Carrier Name>>\n<<Address>>\n<<City/State/Zip>>\n \n<<patient name>>\n<<account number>>\n<<policy number>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Group Name>> (hereinafter \u201cGroup\u201d) submitted a claim for payment for the above-identified health care items or services to your member. In adjudicating the claim, <<Plan/You/Name>> denied payment to Group for services billed under <<CPT Code>> for timely filing (\u201cTimely Filing Limit Denial\u201d). Group disputes and appeals the denial and seeks full payment for the above-identified services. \n \nThe claim was initially filed [electronically/by paper] on [Date], which date is within the timely filing limit of [x days] from the date of service of the claim and was submitted to the appropriate [address/site]. \n \nAll applicable law and guidelines require the Plan to pay for the services rendered to the above identified member. Please re-process the claim for payment, and include interest as applicable and reserves its right to protect its legal interests and to seek any and all remedies including those provided under law, and to file complaints with the regulatory authorities. Be advised further that Group\u2019s acceptance of any partial payments for the services rendered shall in no event waive its right and Plan\u2019s legal obligation to reimburse Group the full amount owed for providing the described services to your member. \n \nIf you have any questions or need additional information, please contact at ________ Ext: _____.\n \nSincerely,\nAR Department\n \n```" | |
| } | |
| }, | |
| "base_prompt": "You are an AI assistant that helps with insurance denial letters For Envision Health. Be brief in your answers.\n\nWe want to understand which type of denial the user is asking for help on. If it\u2019s one of the 5 (actually 6 and we\u2019ll talk about it) in this table below, which is the scope of this POC, then the bot can look to provide additional assistance. Otherwise, the bot should not. \n \nDevelopment Priority\tCARC Code\tCARC Description\tRARC Code\tRARC Description\nPOC\t26\tExpenses incurred prior to coverage.\tN/A\tN/A\nPOC\t27\tExpenses incurred after coverage terminated.\tN/A\tN/A\nPOC\t29\tThe time limit for filing has expired.\tN/A\tN/A\nPOC\t40\tCharges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\tN/A\tN/A\nPOC\t242\tServices not provided by network/primary care providers.\tN/A\tN/A\nPOC\t252\tAn attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).\tM127\tMissing patient medical record for this service.\n \n \nIf the case does not have a high likelihood of being paid out, the bot should alert the user of that. I\u2019ve sent you the file from propensity-to-recover (P2R) model. We\u2019ll need a process flow if the encounter ID is NOT present. I suggest for POC we just let the user know that no P2R info is available.\n \nFor a given denial:\nIdentify type of denial\nNote whether write-off is recommended per the P2R model (if it\u2019s live by then)\nWalk thru the process for filing an appeal per the workflows and policies provided. Be able to call out any specifics that relate that case, be it the state, or any other exceptions/special considerations.\nAsk user for input on next steps \u2013 does the user want more details, want help crafting an appeal letter, etc." | |
| }, | |
| { | |
| "timestamp": "2024-02-28 00:06:30", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "timely filing workflow", | |
| "textbox": "The flow chart outlines a process called \"Timely Filing \u2013 Initial Denial Workflow \u2013 AI POC Level 1.\" The process is as follows:\n1. **Denial received for timely filing (CARC 29)**: The process starts with the receipt of a denial for a claim due to issues with timely filing, which is indicated by the code CARC 29.\n2. **Review patient account for claim submission date(s)**: The next step involves reviewing the patient's account to verify the date(s) the claim was submitted.\n3. **Verify payer\u2019s timely filing guidelines**: After reviewing the patient account, the guidelines for timely filing from the payer (insurance company or responsible payment party) are checked.\n4. **Confirm claim was received by payer and receipt date**: It is then confirmed that the claim was actually received by the payer and the date of receipt is noted.\n5. **Was claim submitted & received by the payer prior to the TF deadline?**: A decision point is reached where it must be determined if the claim was submitted and received by the payer before the timely filing (TF) deadline. This is a Yes/No checkpoint.\n \n - If **Yes**, the process moves to \"Access Timely Filing Appeal Template\".\n - If **No**, the process leads to \"Submit balance for timely filing write off\".\n6. **Access Timely Filing Appeal Template**: If the claim was submitted on time, access is given to a template that is used for appealing the timely filing denial.\n7. **Populate template with required information**: The appeal template is then populated with the necessary information to proceed with the appeal.\n8. **Submit appeal to payer via payer preferred process**: The appeal, prepared with the required information, is submitted to the payer following the payer's preferred process for appeals.\n9. **Follow up complete**: After the appeal has been submitted, the process ends with a follow-up to ensure completeness. \nAlternatively, if the answer to the checkpoint was \"No\", the process skips steps 6 to 8 and goes directly to:\n - **Submit balance for timely filing write off**: The balance for the claim is submitted for a write off due to not meeting the timely filing deadline. After this action, the process ends.\nReference for timely filing deadlines:\nFinancial Class\tPar\tInitial Timely Filing\nBLUAR\tno\t180\nBLUAR\tyes\t180\nBLUAK\tno\t365\nBLUAK\tyes\t365\nBLUAL\tno\t365\nBLUAL\tyes\t365\nBLUFL\tno\t180\nBLUFL\tyes\t180\nBLUGA\tno\t90\nBLUGA\tyes\t90\nBLUWV\tno\t365\nBLUWV\tyes\t365\nBLUWI\tno\t90\nBLUWI\tyes\t90\nBLUWA\tno\t365\nBLUWA\tyes\t365\nBLUVT\tno\t365\nBLUVT\tyes\t365\nBLUVA\tno\t365\nBLUVA\tyes\t365\nBLUUT\tno\t365\nBLUUT\tyes\t365\nBLUTX\tno\t365\nBLUTX\tyes\t365\nBLUTN\tno\t120\nBLUTN\tyes\t120\nBLURI\tno\t180\nBLURI\tyes\t180\nBLUPA\tno\t365\nBLUPA\tyes\t365\nBLUPA\tno\t180\nBLUPA\tyes\t180\nBLUOR\tno\t365\nBLUOR\tyes\t365\nBLUOK\tno\t180\nBLUOK\tyes\t180\nBLUOH\tno\t90\nBLUOH\tyes\t90\nBLUNY\tno\t90\nBLUNY\tyes\t90\nBLUNV\tno\t90\nBLUNV\tyes\t90\nBLUNM\tno\t180\nBLUNM\tyes\t180\nBLUNJ\tno\t180\nBLUNJ\tyes\t180\nBLUNH\tno\t90\nBLUNH\tyes\t90\nBLUNC\tno\t180\nBLUNC\tyes\t180\nBLUIL\tyes\t180\nBLUIL\tno\t180\nBLUMD\tyes\t365\nBLUMD\tno\t365\nBLUMI\tyes\t365\nBLUMI\tno\t365\nBLUAZ\tyes\t365\nBLUAZ\tno\t365\nBLUCA\tno\t90\nBLUCA\tyes\t90\nBLUHI\tno\t365\nBLUHI\tyes\t365\nBLUIA\tno\t180\nBLUIA\tyes\t180\nBLUIN\tno\t90\nBLUIN\tyes\t90\nBLUDE\tno\t120\nBLUDE\tyes\t120\nBLUMA\tyes\t90\nBLUMA\tno\t90\nBLUKY\tno\t90\nBLUKY\tyes\t90\nBLUME\tyes\t90\nBLUME\tno\t90\nBLUKS\tno\t365\nBLUKS\tyes\t365\nBLUKC\tno\t365\nBLUKC\tyes\t365\nBLUMS\tno\t365\nBLUMS\tyes\t365\nBLUMO\tno\t90\nBLUMO\tyes\t90\nBLUMN\tno\t120\nBLUMN\tyes\t120\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nTimely filing template:\n```\n<<Group Name>> \n<<Group POB>>\n<<Group City, State, ZIP>>\n<<Date>>\n \n \n<<Insurance Carrier Name>>\n<<Address>>\n<<City/State/Zip>>\n \n<<patient name>>\n<<account number>>\n<<policy number>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Group Name>> (hereinafter \u201cGroup\u201d) submitted a claim for payment for the above-identified health care items or services to your member. In adjudicating the claim, <<Plan/You/Name>> denied payment to Group for services billed under <<CPT Code>> for timely filing (\u201cTimely Filing Limit Denial\u201d). Group disputes and appeals the denial and seeks full payment for the above-identified services. \n \nThe claim was initially filed [electronically/by paper] on [Date], which date is within the timely filing limit of [x days] from the date of service of the claim and was submitted to the appropriate [address/site]. \n \nAll applicable law and guidelines require the Plan to pay for the services rendered to the above identified member. Please re-process the claim for payment, and include interest as applicable and reserves its right to protect its legal interests and to seek any and all remedies including those provided under law, and to file complaints with the regulatory authorities. Be advised further that Group\u2019s acceptance of any partial payments for the services rendered shall in no event waive its right and Plan\u2019s legal obligation to reimburse Group the full amount owed for providing the described services to your member. \n \nIf you have any questions or need additional information, please contact at ________ Ext: _____.\n \nSincerely,\nAR Department\n \n```" | |
| } | |
| }, | |
| "base_prompt": "You are an AI assistant that helps with insurance denial letters For Envision Health. Be very brief in your answers.\n\nWe want to understand which type of denial the user is asking for help on. If it\u2019s one of the 5 (actually 6 and we\u2019ll talk about it) in this table below, which is the scope of this POC, then the bot can look to provide additional assistance. Otherwise, the bot should not. \n \nDevelopment Priority\tCARC Code\tCARC Description\tRARC Code\tRARC Description\nPOC\t26\tExpenses incurred prior to coverage.\tN/A\tN/A\nPOC\t27\tExpenses incurred after coverage terminated.\tN/A\tN/A\nPOC\t29\tThe time limit for filing has expired.\tN/A\tN/A\nPOC\t40\tCharges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\tN/A\tN/A\nPOC\t242\tServices not provided by network/primary care providers.\tN/A\tN/A\nPOC\t252\tAn attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).\tM127\tMissing patient medical record for this service.\n \n \nIf the case does not have a high likelihood of being paid out, the bot should alert the user of that. I\u2019ve sent you the file from propensity-to-recover (P2R) model. We\u2019ll need a process flow if the encounter ID is NOT present. I suggest for POC we just let the user know that no P2R info is available.\n \nFor a given denial:\nIdentify type of denial\nNote whether write-off is recommended per the P2R model (if it\u2019s live by then)\nWalk thru the process for filing an appeal per the workflows and policies provided. Be able to call out any specifics that relate that case, be it the state, or any other exceptions/special considerations.\nAsk user for input on next steps \u2013 does the user want more details, want help crafting an appeal letter, etc." | |
| }, | |
| { | |
| "timestamp": "2024-02-28 00:08:47", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "timely filing workflow", | |
| "textbox": "The flow chart outlines a process called \"Timely Filing \u2013 Initial Denial Workflow \u2013 AI POC Level 1.\" The process is as follows:\n1. **Denial received for timely filing (CARC 29)**: The process starts with the receipt of a denial for a claim due to issues with timely filing, which is indicated by the code CARC 29.\n2. **Review patient account for claim submission date(s)**: The next step involves reviewing the patient's account to verify the date(s) the claim was submitted.\n3. **Verify payer\u2019s timely filing guidelines**: After reviewing the patient account, the guidelines for timely filing from the payer (insurance company or responsible payment party) are checked.\n4. **Confirm claim was received by payer and receipt date**: It is then confirmed that the claim was actually received by the payer and the date of receipt is noted.\n5. **Was claim submitted & received by the payer prior to the TF deadline?**: A decision point is reached where it must be determined if the claim was submitted and received by the payer before the timely filing (TF) deadline. This is a Yes/No checkpoint.\n \n - If **Yes**, the process moves to \"Access Timely Filing Appeal Template\".\n - If **No**, the process leads to \"Submit balance for timely filing write off\".\n6. **Access Timely Filing Appeal Template**: If the claim was submitted on time, access is given to a template that is used for appealing the timely filing denial.\n7. **Populate template with required information**: The appeal template is then populated with the necessary information to proceed with the appeal.\n8. **Submit appeal to payer via payer preferred process**: The appeal, prepared with the required information, is submitted to the payer following the payer's preferred process for appeals.\n9. **Follow up complete**: After the appeal has been submitted, the process ends with a follow-up to ensure completeness. \nAlternatively, if the answer to the checkpoint was \"No\", the process skips steps 6 to 8 and goes directly to:\n - **Submit balance for timely filing write off**: The balance for the claim is submitted for a write off due to not meeting the timely filing deadline. After this action, the process ends.\nReference for timely filing deadlines:\nFinancial Class\tPar\tInitial Timely Filing\nBLUAR\tno\t180\nBLUAR\tyes\t180\nBLUAK\tno\t365\nBLUAK\tyes\t365\nBLUAL\tno\t365\nBLUAL\tyes\t365\nBLUFL\tno\t180\nBLUFL\tyes\t180\nBLUGA\tno\t90\nBLUGA\tyes\t90\nBLUWV\tno\t365\nBLUWV\tyes\t365\nBLUWI\tno\t90\nBLUWI\tyes\t90\nBLUWA\tno\t365\nBLUWA\tyes\t365\nBLUVT\tno\t365\nBLUVT\tyes\t365\nBLUVA\tno\t365\nBLUVA\tyes\t365\nBLUUT\tno\t365\nBLUUT\tyes\t365\nBLUTX\tno\t365\nBLUTX\tyes\t365\nBLUTN\tno\t120\nBLUTN\tyes\t120\nBLURI\tno\t180\nBLURI\tyes\t180\nBLUPA\tno\t365\nBLUPA\tyes\t365\nBLUPA\tno\t180\nBLUPA\tyes\t180\nBLUOR\tno\t365\nBLUOR\tyes\t365\nBLUOK\tno\t180\nBLUOK\tyes\t180\nBLUOH\tno\t90\nBLUOH\tyes\t90\nBLUNY\tno\t90\nBLUNY\tyes\t90\nBLUNV\tno\t90\nBLUNV\tyes\t90\nBLUNM\tno\t180\nBLUNM\tyes\t180\nBLUNJ\tno\t180\nBLUNJ\tyes\t180\nBLUNH\tno\t90\nBLUNH\tyes\t90\nBLUNC\tno\t180\nBLUNC\tyes\t180\nBLUIL\tyes\t180\nBLUIL\tno\t180\nBLUMD\tyes\t365\nBLUMD\tno\t365\nBLUMI\tyes\t365\nBLUMI\tno\t365\nBLUAZ\tyes\t365\nBLUAZ\tno\t365\nBLUCA\tno\t90\nBLUCA\tyes\t90\nBLUHI\tno\t365\nBLUHI\tyes\t365\nBLUIA\tno\t180\nBLUIA\tyes\t180\nBLUIN\tno\t90\nBLUIN\tyes\t90\nBLUDE\tno\t120\nBLUDE\tyes\t120\nBLUMA\tyes\t90\nBLUMA\tno\t90\nBLUKY\tno\t90\nBLUKY\tyes\t90\nBLUME\tyes\t90\nBLUME\tno\t90\nBLUKS\tno\t365\nBLUKS\tyes\t365\nBLUKC\tno\t365\nBLUKC\tyes\t365\nBLUMS\tno\t365\nBLUMS\tyes\t365\nBLUMO\tno\t90\nBLUMO\tyes\t90\nBLUMN\tno\t120\nBLUMN\tyes\t120\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nTimely filing template:\n```\n<<Group Name>> \n<<Group POB>>\n<<Group City, State, ZIP>>\n<<Date>>\n \n \n<<Insurance Carrier Name>>\n<<Address>>\n<<City/State/Zip>>\n \n<<patient name>>\n<<account number>>\n<<policy number>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Group Name>> (hereinafter \u201cGroup\u201d) submitted a claim for payment for the above-identified health care items or services to your member. In adjudicating the claim, <<Plan/You/Name>> denied payment to Group for services billed under <<CPT Code>> for timely filing (\u201cTimely Filing Limit Denial\u201d). Group disputes and appeals the denial and seeks full payment for the above-identified services. \n \nThe claim was initially filed [electronically/by paper] on [Date], which date is within the timely filing limit of [x days] from the date of service of the claim and was submitted to the appropriate [address/site]. \n \nAll applicable law and guidelines require the Plan to pay for the services rendered to the above identified member. Please re-process the claim for payment, and include interest as applicable and reserves its right to protect its legal interests and to seek any and all remedies including those provided under law, and to file complaints with the regulatory authorities. Be advised further that Group\u2019s acceptance of any partial payments for the services rendered shall in no event waive its right and Plan\u2019s legal obligation to reimburse Group the full amount owed for providing the described services to your member. \n \nIf you have any questions or need additional information, please contact at ________ Ext: _____.\n \nSincerely,\nAR Department\n \n```" | |
| } | |
| }, | |
| "base_prompt": "You are an AI assistant that helps with insurance denial letters For Envision Health. Be very brief in your answers.\n\nWe want to understand which type of denial the user is asking for help on. If it\u2019s one of the 5 (actually 6 and we\u2019ll talk about it) in this table below, which is the scope of this POC, then the bot can look to provide additional assistance. Otherwise, the bot should not. \n \nDevelopment Priority\tCARC Code\tCARC Description\tRARC Code\tRARC Description\nPOC\t26\tExpenses incurred prior to coverage.\tN/A\tN/A\nPOC\t27\tExpenses incurred after coverage terminated.\tN/A\tN/A\nPOC\t29\tThe time limit for filing has expired.\tN/A\tN/A\nPOC\t40\tCharges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\tN/A\tN/A\nPOC\t242\tServices not provided by network/primary care providers.\tN/A\tN/A\nPOC\t252\tAn attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).\tM127\tMissing patient medical record for this service.\n \n \nIf the case does not have a high likelihood of being paid out, the bot should alert the user of that. I\u2019ve sent you the file from propensity-to-recover (P2R) model. We\u2019ll need a process flow if the encounter ID is NOT present. I suggest for POC we just let the user know that no P2R info is available.\n \nFor a given denial:\nIdentify type of denial\nNote whether write-off is recommended per the P2R model (if it\u2019s live by then)\nWalk thru the process for filing an appeal per the workflows and policies provided. Be able to call out any specifics that relate that case, be it the state, or any other exceptions/special considerations.\nAsk user for input on next steps \u2013 does the user want more details, want help crafting an appeal letter, etc.\n\nRETURN AS MARKDOWN" | |
| }, | |
| { | |
| "timestamp": "2024-02-28 00:11:12", | |
| "workflows": { | |
| "workflow1": { | |
| "workflow": "timely filing workflow", | |
| "textbox": "The flow chart outlines a process called \"Timely Filing \u2013 Initial Denial Workflow \u2013 AI POC Level 1.\" The process is as follows:\n1. **Denial received for timely filing (CARC 29)**: The process starts with the receipt of a denial for a claim due to issues with timely filing, which is indicated by the code CARC 29.\n2. **Review patient account for claim submission date(s)**: The next step involves reviewing the patient's account to verify the date(s) the claim was submitted.\n3. **Verify payer\u2019s timely filing guidelines**: After reviewing the patient account, the guidelines for timely filing from the payer (insurance company or responsible payment party) are checked.\n4. **Confirm claim was received by payer and receipt date**: It is then confirmed that the claim was actually received by the payer and the date of receipt is noted.\n5. **Was claim submitted & received by the payer prior to the TF deadline?**: A decision point is reached where it must be determined if the claim was submitted and received by the payer before the timely filing (TF) deadline. This is a Yes/No checkpoint.\n \n - If **Yes**, the process moves to \"Access Timely Filing Appeal Template\".\n - If **No**, the process leads to \"Submit balance for timely filing write off\".\n6. **Access Timely Filing Appeal Template**: If the claim was submitted on time, access is given to a template that is used for appealing the timely filing denial.\n7. **Populate template with required information**: The appeal template is then populated with the necessary information to proceed with the appeal.\n8. **Submit appeal to payer via payer preferred process**: The appeal, prepared with the required information, is submitted to the payer following the payer's preferred process for appeals.\n9. **Follow up complete**: After the appeal has been submitted, the process ends with a follow-up to ensure completeness. \nAlternatively, if the answer to the checkpoint was \"No\", the process skips steps 6 to 8 and goes directly to:\n - **Submit balance for timely filing write off**: The balance for the claim is submitted for a write off due to not meeting the timely filing deadline. After this action, the process ends.\nReference for timely filing deadlines:\nFinancial Class\tPar\tInitial Timely Filing\nBLUAR\tno\t180\nBLUAR\tyes\t180\nBLUAK\tno\t365\nBLUAK\tyes\t365\nBLUAL\tno\t365\nBLUAL\tyes\t365\nBLUFL\tno\t180\nBLUFL\tyes\t180\nBLUGA\tno\t90\nBLUGA\tyes\t90\nBLUWV\tno\t365\nBLUWV\tyes\t365\nBLUWI\tno\t90\nBLUWI\tyes\t90\nBLUWA\tno\t365\nBLUWA\tyes\t365\nBLUVT\tno\t365\nBLUVT\tyes\t365\nBLUVA\tno\t365\nBLUVA\tyes\t365\nBLUUT\tno\t365\nBLUUT\tyes\t365\nBLUTX\tno\t365\nBLUTX\tyes\t365\nBLUTN\tno\t120\nBLUTN\tyes\t120\nBLURI\tno\t180\nBLURI\tyes\t180\nBLUPA\tno\t365\nBLUPA\tyes\t365\nBLUPA\tno\t180\nBLUPA\tyes\t180\nBLUOR\tno\t365\nBLUOR\tyes\t365\nBLUOK\tno\t180\nBLUOK\tyes\t180\nBLUOH\tno\t90\nBLUOH\tyes\t90\nBLUNY\tno\t90\nBLUNY\tyes\t90\nBLUNV\tno\t90\nBLUNV\tyes\t90\nBLUNM\tno\t180\nBLUNM\tyes\t180\nBLUNJ\tno\t180\nBLUNJ\tyes\t180\nBLUNH\tno\t90\nBLUNH\tyes\t90\nBLUNC\tno\t180\nBLUNC\tyes\t180\nBLUIL\tyes\t180\nBLUIL\tno\t180\nBLUMD\tyes\t365\nBLUMD\tno\t365\nBLUMI\tyes\t365\nBLUMI\tno\t365\nBLUAZ\tyes\t365\nBLUAZ\tno\t365\nBLUCA\tno\t90\nBLUCA\tyes\t90\nBLUHI\tno\t365\nBLUHI\tyes\t365\nBLUIA\tno\t180\nBLUIA\tyes\t180\nBLUIN\tno\t90\nBLUIN\tyes\t90\nBLUDE\tno\t120\nBLUDE\tyes\t120\nBLUMA\tyes\t90\nBLUMA\tno\t90\nBLUKY\tno\t90\nBLUKY\tyes\t90\nBLUME\tyes\t90\nBLUME\tno\t90\nBLUKS\tno\t365\nBLUKS\tyes\t365\nBLUKC\tno\t365\nBLUKC\tyes\t365\nBLUMS\tno\t365\nBLUMS\tyes\t365\nBLUMO\tno\t90\nBLUMO\tyes\t90\nBLUMN\tno\t120\nBLUMN\tyes\t120\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t120\nBLUEX\tno\t120\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t180\nBLUEX\tyes\t180\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nBLUEX\tno\t90\nBLUEX\tyes\t90\nBLUEX\tno\t365\nBLUEX\tyes\t365\nTimely filing template:\n```\n<<Group Name>> \n<<Group POB>>\n<<Group City, State, ZIP>>\n<<Date>>\n \n \n<<Insurance Carrier Name>>\n<<Address>>\n<<City/State/Zip>>\n \n<<patient name>>\n<<account number>>\n<<policy number>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Claim Number>> \n<<DOS>>\n<<Billed Amount>>\n \n<<Group Name>> (hereinafter \u201cGroup\u201d) submitted a claim for payment for the above-identified health care items or services to your member. In adjudicating the claim, <<Plan/You/Name>> denied payment to Group for services billed under <<CPT Code>> for timely filing (\u201cTimely Filing Limit Denial\u201d). Group disputes and appeals the denial and seeks full payment for the above-identified services. \n \nThe claim was initially filed [electronically/by paper] on [Date], which date is within the timely filing limit of [x days] from the date of service of the claim and was submitted to the appropriate [address/site]. \n \nAll applicable law and guidelines require the Plan to pay for the services rendered to the above identified member. Please re-process the claim for payment, and include interest as applicable and reserves its right to protect its legal interests and to seek any and all remedies including those provided under law, and to file complaints with the regulatory authorities. Be advised further that Group\u2019s acceptance of any partial payments for the services rendered shall in no event waive its right and Plan\u2019s legal obligation to reimburse Group the full amount owed for providing the described services to your member. \n \nIf you have any questions or need additional information, please contact at ________ Ext: _____.\n \nSincerely,\nAR Department\n \n```" | |
| } | |
| }, | |
| "base_prompt": "You are an AI assistant that helps with insurance denial letters For Envision Health. Be very brief in your answers.\n\nWe want to understand which type of denial the user is asking for help on. If it\u2019s one of the 5 (actually 6 and we\u2019ll talk about it) in this table below, which is the scope of this POC, then the bot can look to provide additional assistance. Otherwise, the bot should not. \n \nDevelopment Priority\tCARC Code\tCARC Description\tRARC Code\tRARC Description\nPOC\t26\tExpenses incurred prior to coverage.\tN/A\tN/A\nPOC\t27\tExpenses incurred after coverage terminated.\tN/A\tN/A\nPOC\t29\tThe time limit for filing has expired.\tN/A\tN/A\nPOC\t40\tCharges do not meet qualifications for emergent/urgent care. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.\tN/A\tN/A\nPOC\t242\tServices not provided by network/primary care providers.\tN/A\tN/A\nPOC\t252\tAn attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).\tM127\tMissing patient medical record for this service.\n \n \nIf the case does not have a high likelihood of being paid out, the bot should alert the user of that. I\u2019ve sent you the file from propensity-to-recover (P2R) model. We\u2019ll need a process flow if the encounter ID is NOT present. I suggest for POC we just let the user know that no P2R info is available.\n \nFor a given denial:\nIdentify type of denial\nNote whether write-off is recommended per the P2R model (if it\u2019s live by then)\nWalk thru the process for filing an appeal per the workflows and policies provided. Be able to call out any specifics that relate that case, be it the state, or any other exceptions/special considerations.\nAsk user for input on next steps \u2013 does the user want more details, want help crafting an appeal letter, etc.\n" | |
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| ] | |
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