FIRSTSOURCE · Healthcare Claims ICF

Layer 0 · Data Ingestion

INTELLIGENT CONTEXT FRAMEWORK

Load and validate input sources for the Healthcare Claims ICF. Required sources activate the intelligence layer and unlock downstream analytics, gap detection, SOP review, and intelligence query capabilities.

10,275

Claims Sessions

41

Gaps Detected

65%

FTR · BM 72%

2.9%

Escalation Rate

13.7%

Denial Rate

400

Denied—No Reason

INPUT SOURCES

Select Data Sources to Ingest

REQUIRED · LOADED

📊

Claims Event / Transaction Logs

HC_Claims_Final_v3.xlsx — structured claims event data across 14 scenario types. Primary analytics source for all gap detection, KPI computation, and trend analysis.

10,275

CLAIM SESSIONS

14 SCENARIO TYPES 90-DAY ROLLING XLSX FORMAT

REQUIRED · LOADED

📋

SOPs / Relevant Artefacts

HC_Claims_SOPs.docx — 7 standard operating procedures covering all claim handling workflows. Source of all SOP revision recommendations, knowledge base articles, and intelligence grounding.

7

SOP DOCUMENTS

SOP-HC-01 → 07 DOCX FORMAT 10 REVISIONS READY

Claims Data ParsingWaiting

SOP Extraction & TokenisationWaiting

Gap Detection EngineWaiting

KPI ComputationWaiting

Knowledge Graph BuildWaiting

✓ Ingestion complete — 10,275 claim sessions analysed · 41 gaps detected · 5 categories · All layers activated

ICF ACTIVATION PIPELINE

1

Source Validation

Verify required files present and schema-compliant

2

SOP Parse & Index

Extract SOP sections and build searchable index

3

Claims Analytics

Compute KPIs across 14 scenario types

4

Gap Detection

Flag compliance, process, SOP, training and product gaps

5

Knowledge Graph

Build domain-specific ICF graph with 40 nodes

6

Intelligence Activation

Grounded QA enabled across all SOPs and claims data

SCOPE & COVERAGE

CLAIMS DATA

HC_Claims_Final_v3.xlsx — 10,275 sessions · 14 scenario types · Cigna-equivalent payer · Rolling 90-day window.

SOP KNOWLEDGE

7 SOPs indexed (SOP-HC-01 through SOP-HC-07). 41 gaps grounded to SOP source sections. 8 KB categories active.

OUTPUTS GENERATED

41 Gaps · 10 SOP revisions · 8 training modules · 12 advisories · 40-node knowledge graph · Intelligence layer activated.

Layer 1 · Volume & Quality Analytics

CLAIMS ANALYSIS

Performance metrics across 10,275 claim sessions. KPI benchmarks, volume distribution, gap profile, and quality indicators by scenario type.

10,275

Total Sessions

65%

FTR · BM 72%

2.9%

Escalation Rate

3.9%

Rework Claim Rate

13.7%

Denial Rate

7m 45s

APT · TQ 6m 30s

4.9%

SLA Breach

41

Gaps Detected

FTR vs Benchmark

65%

Benchmark: 72% · −7pp gap

APT vs Top Quartile

7m 45s

Top Quartile: 6m 30s · +75s over

Denied — No Reason

400

3.9% of total · CMS compliance risk

CRITICAL GAP · GAP-C01

SLA Breach (30-Day)

500

4.9% of total · CMS §1557 threshold

CRITICAL GAP · GAP-C02

Claim Volume by Scenario Type

Resolution Mix — 10,275 Sessions

Gap Profile by Type — 41 Total

Compliance & Quality Summary

First Touch Resolution

65% vs 72%

Denial Rate

13.7% total

Denied — No Reason Code

400 claims

SLA Breach (CMS 30-Day)

500 claims

LPI-State Exposure

10 states

Rework Claim Rate

3.9%

Escalation Rate

2.9%

Active Nodes (ICF Graph)

40 nodes

Layer 1 · Knowledge Structure

ICF GRAPH

40-node force-directed knowledge graph mapping domain entities, claim scenarios, system fields, compliance triggers, and SOP relationships. Click any node for full detail.

40

Active Nodes

38

Edge Connections

5

Domain Layers

41

Gaps Mapped

SCENARIO: SHOW:

◎

Select a node to inspect its
sessions, flags and
evidence trace.

Layer 1 · Intelligence Gaps

GAP REGISTER

41 grounded gaps across 5 categories, sourced from HC_Claims_Final_v3.xlsx and SOP-HC-01 through SOP-HC-07. Expandable evidence traces with source references.

41

Total Gaps

2

Compliance · Critical

11

Process · Critical/High

10

SOP Revision

9

Training Gaps

9

Product / System

Compliance

2

CMS 30-day mandate & denial reason code gaps

Process

11

Workflow, routing and escalation execution gaps

SOP

10

SOP language, scope and completeness revisions

Training

9

Agent skill, product knowledge and tool gaps

Product

9

Facets/TriZetto system and tooling deficiencies

TYPE: SEV:

Layer 2 · SOP Intelligence

SOP REVIEWS

10 grounded SOP revision recommendations derived from gap analysis. Each card shows current text, proposed revision, rationale and source evidence.

10

Revisions

0

Incorporated

0

Ignored

10

Pending

Layer 2 · Agent Development

TRAINING MODULES

8 structured training interventions addressing identified skill and knowledge gaps. Modules include OPR-ALPHA and OPR-BETA cohort assignments.

8

Modules

2

Cohorts

9

Training Gaps Addressed

OPR-ALPHA COHORT

OPR-BETA COHORT

PERFORMANCE APPRAISALS · COACHING INTELLIGENCE

Agent Development Review

Layer 2 · Operational Intelligence

PROCESS, PRODUCT & COMPLIANCE ADVISORIES

14 grounded advisories (2 compliance, 6 process, 6 product/system) with actionable interventions, expected outcomes, and ownership assignments.

14

Total Advisories

2

Compliance Advisories

6

Process Advisories

6

Product Advisories

COMPLIANCE ADVISORIES

PROCESS ADVISORIES

PRODUCT / SYSTEM ADVISORIES

Layer 3 · Executive Intelligence

DEEP DIVE

Scenario-based gap breakdown, compliance exposure analysis, financial risk calculation, SLA analysis, and functional drill-down across all claim types.

$127K+

Est. LPI Exposure

400

Denied—No Reason (CMS)

500

SLA Breach (30-Day)

65%

FTR · −7pp vs BM

EXECUTIVE SUMMARY

2 critical compliance gaps demand immediate remediation: 400 claims denied without reason codes (CMS §§1852, 1902 violation) and 500 claims breaching the 30-day processing window. FTR of 65% vs 72% benchmark reflects SOP coverage gaps across denial handling, LPI calculation and COB processing. $127K+ in LPI interest exposure across CA, TX, NY, FL, NC, OH, PA, GA, IL and VA. 10 SOP revisions ready for incorporation; 8 training modules targeting OPR-ALPHA and OPR-BETA cohorts.

VOLUME BREAKDOWN

COMPLIANCE

FINANCIAL RULES

SLA ANALYSIS

FUNCTIONAL DRILL-DOWN

Scenario Volume Distribution

Gap Severity by Scenario

Scenarios ranked by total gap severity score. Critical gaps appear in Denied—No Reason, SLA Breach, and Claim On Hold clusters.

Denied — No Reason

CRITICAL

SLA Breach

CRITICAL

Claim On Hold

HIGH

Denied — With Reason

HIGH

LPI Assessed

HIGH

Escalated

MEDIUM

Partial Payment

MEDIUM

Late Payment Interest (LPI)

LPI = PAID_AMOUNT × 1.8% / 365 × DAYS_LATE

Triggered when claims exceed state-mandated processing windows. LPITOOL_LPI_STATE field in Facets/TriZetto governs activation. Applies in CA, TX, NY, FL, NC, OH, PA, GA, IL, VA.

⚠ 200 LPI-assessed claims in dataset · est. $127K+ exposure

Coordination of Benefits (COB)

COB_PAYABLE = MIN(CHG − PRI_PAID, ALLOW − PRI_PAID)

Secondary payer liability calculated as minimum of two amounts: (a) charged amount minus primary payment, (b) allowed amount minus primary payment. CDML_DISALL_EXCD drives COB exception tracking.

Payment Hierarchy Rule

PAID ≤ ALLOWED ≤ CHARGED

Fundamental claims validation: paid amount cannot exceed allowed amount, which cannot exceed original charged amount. Violations flagged in CLCL_CUR_STS field.

LPI State Exposure Breakdown

California (CA)

Highest risk

Texas (TX)

High volume

New York (NY)

High rate

Florida (FL)

Medium

North Carolina (NC)

Medium

Ohio (OH)

Lower

Pennsylvania (PA)

Lower

Georgia (GA)

Lower

Illinois (IL)

Lower

Virginia (VA)

Lower

Key Facets / TriZetto Fields

Field	Purpose
CLCL_CUR_STS	Claim current status code
WMHS_TURNARND_DAYS	Processing turnaround days
EXCD_SHORT_TEXT	Denial exception short text
CDML_DISALL_EXCD	Disallowance exception code
ERISA_IND	ERISA plan indicator flag
LPITOOL_LPI_STATE	LPI calculation state
ML_MODEL / ML_SCORE	ML prediction model & score

500

SLA Breaches

Exceed 30-day CMS window

4.9%

Breach Rate

Of 10,275 total

30

Day Mandate

CMS §1557 requirement

WMHS

Tracking Field

WMHS_TURNARND_DAYS

CMS COMPLIANCE ALERT

500 claims exceed the 30-day processing window mandated under CMS §1557 and ACA §1001. This constitutes a systemic compliance breach requiring immediate escalation to the compliance team. WMHS_TURNARND_DAYS field must be monitored in real-time dashboards with automated alerts at 25-day threshold.

SLA Performance by Scenario

SLA Breach (On Hold)

500 claims

Escalated Claims

300 claims

In Process >20 Days

est. 200+

Denied Awaiting Rework

est. 150+

Recommended SLA Controls

1. Real-time WMHS monitoring: Automated alert at 25-day threshold, escalation at 28 days, supervisor review at 30.

2. Hold Queue Triage: Daily review of Claim On Hold inventory with priority scoring based on WMHS_TURNARND_DAYS.

3. SOP-HC-04 Escalation Update: Revise escalation trigger from 30 days to 25 days to buffer CMS deadline.

4. Compliance Reporting: Monthly SLA breach report to compliance team with root cause analysis by scenario type.

🔴 Compliance Function

Critical exposure in denial reason code mandates and 30-day processing window adherence. Both gaps require immediate compliance team intervention.

PRIORITY

400 no-reason denials (CMS §§1852/1902) + 500 SLA breaches = 2 simultaneous critical violations

🔶 Operations Function

11 process gaps across LPI calculation, COB processing, hold queue management, duplicate claim routing, and overpayment recovery protocols.

COVERAGE

SOP-HC-01 through SOP-HC-07 all contain process gaps; SOP-HC-04 escalation timing critical

🔵 Training Function

9 training gaps across Facets/TriZetto field usage, LPI state identification, COB calculation methodology, and denial appeal scripting.

COHORTS

OPR-ALPHA (senior agents): advanced LPI + COB · OPR-BETA (new agents): core SOP + Facets basics

Layer 3 · Grounded Knowledge

KNOWLEDGE BASE

8 structured knowledge categories grounded in SOP-HC-01 through SOP-HC-07 and Facets/TriZetto field documentation. Step-by-step agent guidance with compliance language.