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Part 02 · Build

Answer every call first. Then resolve it.

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.

Weeks 3–12 · BuildW4 Every-call intakeW5 Caller authenticationW6 Claim status lookupW10 Appeals & reconsiderationsW11 Denial playbooks

The workflows

  1. W4

    Every-call intake

    The phase-one foundation: every call answered and logged as a structured case, so nothing lands in voicemail again.

    100%
    Calls captured
    Live
  2. W5

    Caller authentication

    Provider billing staff verified with last name, date of service, and tax ID, matched against live claims data.

    3
    Fields to verify
    Live
  3. W6

    Claim status lookup

    The master workflow: live status, total charge, amount paid, and check run date, read back on the line. Multiple matches narrowed by billed charges.

    60%
    Of searchable claims resolved
    Live
  4. W10

    Appeals & reconsiderations

    Appeals filed on the call, whether the claim is found or not, with claim and appeal IDs written back to the case.

    577
    Appeals in scope monthly
    Live
  5. W11

    Denial playbooks

    Denial-specific handling: policy scripts that route callers to the right external process and count as resolved, not abandoned.

    By reason
    Scripted handling
    Live
  6. -

    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.

    36%
    Of denial reasons
    In flight

Anatomy of a resolved call

Inside a workflow: claim status

What actually 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.

  1. 01

    Authenticate the caller with last name, date of service, and tax ID, matched against live claims data.

    Claims data warehouse
    Auto
  2. 02

    Classify intent from the caller's own words; billing staff can switch to another claim mid-call without starting over.

    Auto
  3. 03

    Pull the claim: current status, total charge, amount paid, and check run date.

    Claims API · real-time
    Auto
  4. 04

    Resolve on the line: read the status and payment detail back, narrowing multiple matches by billed charges.

    Auto
  5. 05

    Five or more identical claims, or anything outside policy, transfers to a specialist with the full context attached.

    CRM case queue
    Human
  6. 06

    Write the disposition back as a case: closed if resolved on the line, open with structured detail if it needs a person.

    CRM
    Auto
Measured in production
100%
Calls answered
Up from one in four
60%
Searchable claims resolved
23% of all calls, climbing
~86%
Deflection ceiling
As eligibility data comes online