Intake and Resolution Workflows
Phase one put a structured case behind every call, taking coverage from one in four to all of them. Phase two wired the workflows into live claims data, so status, payments, and appeals resolve on the line.
Build Phases
- Phase 1Weeks 3–4
Call Coverage
One intake workflow puts a structured case behind every call, so nothing lands in voicemail again.
1 in 4 → 100%Calls answered- W4Call IntakeShipped
- Phase 2Weeks 5–12
Resolution on the Call
Workflows wired into live claims data, so status, payments, and appeals close during the call.
0 → 23%Calls resolved without a person- W5Caller AuthenticationShipped
- W6Claim Status LookupShipped
- W10Appeals & ReconsiderationsShipped
- W11Denial PlaybooksShipped
- NextIn flight
Next Endpoints
Each data endpoint the client ships moves another call type from a ticket to an answer.
~86%Deflection ceiling- - Eligibility LookupsIn flight
The Workflows
- W4
Call Intake
The phase-one foundation: every call answered and logged as a structured case, so nothing lands in voicemail again.
Shipped100%Calls captured - W5
Caller Authentication
Provider billing staff verified against live claims data with last name, date of service, and tax ID.
Shipped3Fields to verify - W6
Claim Status Lookup
The master workflow reads back live status, total charge, amount paid, and check run date on the line. Multiple matches narrowed by billed charges.
Shipped60%Of searchable claims resolved - W10
Appeals & Reconsiderations
Appeals filed on the call whether or not the claim is found. Claim and appeal IDs are written back to the case.
Shipped577Appeals in scope monthly - W11
Denial Playbooks
Denial-specific handling: policy scripts that route callers to the right external process and count as resolved, not abandoned.
ShippedBy reasonScripted handling - -
Eligibility Lookups
A third of denials trace to eligibility. Today these calls become structured tickets; a patient-data endpoint on the client's roadmap moves them to on-line resolution.
In flight36%Of denial reasons
Resolved Call Detail
Claim Status Workflow
What happens on a deflected call. Automated steps run against the client's live claims API; anything outside policy becomes a structured case for a person, never a dead end.
- 01Auto
Authenticate the caller against live claims data with last name, date of service, and tax ID.
Claims data warehouse - 02Auto
Classify intent from the caller's own words; billing staff can switch to another claim mid-call without starting over.
- 03Auto
Pull the claim: current status, total charge, amount paid, and check run date.
Claims API · real-time - 04Auto
Read the status and payment detail back on the line. Narrow multiple matches by billed charges.
- 05Human
Five or more identical claims or anything outside policy transfers to a specialist with the full context attached.
CRM case queue - 06Auto
Write the disposition back as a case. Close it if resolved on the line, or leave it open with structured detail for a person.
CRM