Claims Eligibility & Pre-Screen Agent

Built for Medicare Administrative Contractors, model participants, and payer operations teams, it removes the manual triage layer between claim intake and clinical review. It is deterministic by design — no model inference, no probabilistic scoring. The same claim always produces the same outcome, fired rule, and reason code, which is what makes decisions auditable to CMS and reproducible under appeal.

It sits alongside PES One (Engagement Lobe, live with 10+ health systems) and CPS One (privacy and AI governance, 76 NPS, 96% three-year retention). Three platforms, one architecture, 11 patent applications filed.

Key Capabilities

• Deterministic WISeR v6.0 Screening: Every claim resolves to SENT_ADR_LETTER, NOT_APPLICABLE, or MANUAL_REVIEW_REQUIRED
• Staged Check Pipeline: PREFLIGHT → D-1 → D-3 → D-4 → D-5, short-circuiting the moment a check produces a final answer
• Payer Scope Exclusion: Medicare Advantage, Railroad Medicare, VA, and IHS claims dismissed before any clinical logic runs
• Appendix A Watchlist: 41 gated procedure codes across all 13 service categories, with date-gating for mid-model code phase-ins
• ICD-10 Clinical Eligibility: Diagnosis allowlists for VNS, SNS, and Skin Substitutes — 63 codes across three gated categories
• Add-On Code Detection: 338 Appendix C codes, so add-on-only claims are dismissed rather than escalated
• ADR Automation: Claims clearing every check are flagged for Additional Documentation Request generation before payment
• Audit-Grade Traceability: Every response includes a plain-language summary, rule-level explanation, and per-check audit trail, with PHI masked in logs
• Configurable Rule Sets: Code lists live in readable Markdown for clinical staff to review and edit directly [decision needed: confirm no-redeploy hot-reload works under the per-tenant Managed Application model before claiming it]

Outcomes Delivered

• Sub-20ms decisions — typical claim resolves in 4-12ms
• Zero-variance outcomes on identical inputs
• 128 automated tests gating every release
• Rule content updates without a full engineering release cycle
• Deployed within the CMS WISeR Innovation Model in New Jersey, covering 1M+ Medicare FFS members
• HIPAA, SOC 2 Type II, and ISO 27001 aligned controls
• [decision needed: add one business-outcome metric — denial-rate reduction, appeal overturn rate, or FTE-hours saved]

Why Choose This Agent

• Deterministic where it counts. Pre-payment dispositions must survive audit and appeal; probabilistic screening isn't defensible at CMS review.
• Proven within an active CMS model. Deployed within the CMS WISeR Innovation Model for 1M+ Medicare FFS members.
• Purpose-built substrate. Runs on Aether One — 11 patent applications filed to date.
• Architectural depth, not a wrapper. Every rule maps to a numbered WISeR v6.0 requirement, including those deliberately not implemented.
• Governance built in. Operates alongside CPS One, Genzeon's privacy and AI-governance platform.
• Integration-ready. One REST screening endpoint plus health, readiness, and version probes. Containerized and Azure-deployed.
• Forward-deployed engineering. Embedded engineers, named clinical reviewers, outcome-committed engagements.

Target Customers

• Medicare Administrative Contractors — Screening high-volume FFS claim feeds before payment
• WISeR Model Participants — Auditable, reproducible pre-payment dispositions
• Health Plans and Payers — Cutting manual triage volume without probabilistic decisioning
• Utilization Management Organizations — Narrowing the reviewable population before clinical staff engage
• Health Systems and Revenue Cycle Teams — Visibility into which claims will attract an ADR letter