The signature mechanic
One inbox in. Skills-based routing out. SLA lanes underneath.
Every follow-up event — from any module — becomes a FHIR Task, then routes by required skill to the right worker and drops into a priority lane with its own SLA clock. A task that ages out doesn't get lost; it escalates with an audit-logged event.
Tasks are FHIR R4 Task resources — status, intent, priority, owner, period — and the AI next-best-action engine weighs task type, denial reason, the payer's historical appeal-success rate, and elapsed time before suggesting “file appeal,” “request peer-to-peer,” or “collect records.”
The problem
Billing follow-up runs on spreadsheets, sticky notes, and one person's memory.
Denials sit until someone remembers them. Payer calls go undocumented — no record of who was spoken to or what was promised. When the one person who knows the Blue Cross appeals process takes a vacation, that queue stalls. Appeal windows close silently, and the revenue is gone for good.
Every action gets a task. Every task gets a clock.
A denied claim becomes a FHIR Task within one minute of the 835 posting — carrying the CARC/RARC reason code, the appeal-window deadline, and an AI-suggested next action. Tasks that age past their SLA auto-escalate to the practice manager with an audit-logged escalation event. Structured process replaces tribal knowledge.
AI that knows the payer's habits
The next-best-action engine weighs the task type, the denial reason, the payer's historical appeal-success rates, and elapsed time. “Request peer-to-peer review — this payer overturns 68% of CARC 29 denials on peer review.” The biller accepts, modifies, or dismisses; either way, the decision is logged and the model learns.
Key capabilities
One queue. Every follow-up. Zero tribal knowledge.
Unified work queue
Denials, follow-ups, co-signs, renewals, referral authorizations, and PA decisions in a single surface with role, type, priority, SLA, and assignee views. Loads in under two seconds.
SLA auto-escalation
Tasks exceeding 30 days in an active state escalate to the practice manager with an Overdue badge and an SMS alert. Rules configurable per task type; every escalation audited.
AI next-best-action
File appeal, call payer, request peer-to-peer, collect records — suggested per task from the denial code, payer history, and elapsed time.
FHIR Task native
Tasks are FHIR R4 Task resources — status, intent, priority, owner, period — enabling payer interoperability through the CMS-0057-F Provider Access API.
Skills-based routing
The workers'-comp denial goes to the biller tagged with that skill; complex appeals reach senior staff; routine follow-ups land on whoever's available.
Appeal macros
Letter templates auto-populated with diagnosis codes, the procedure in question, clinical rationale from the chart, and the payer's own coverage criteria. Twenty minutes of drafting becomes three.
Payer call logging
Outbound calls log automatically with caller ID, duration, and outcome summary; SMS and email follow-ups capture with timestamps. No more undocumented payer interactions.
Provider Access API consumer
For CMS-0057-F-compliant payers, PA status and adjudication details pull through the API — replacing manual portal logins and status-check calls.
Time tracking & analytics
Time per task, per biller, per task type — feeding a real-time dashboard of queue depth, SLA compliance, aging, and AI acceptance rates.
Workflow
A denial's path through the queue.
835 posts; the task exists
Within a minute, the denial is a FHIR Task with its CARC code, appeal deadline, and a suggested action.
Routed by skill
It's a medical-necessity denial requiring clinical narrative — routing sends it to the biller with that specialty, not the general pile.
Macro drafts the appeal
The Level II appeal letter pre-populates with diagnosis codes, clinical rationale from the chart, and the payer's own coverage criteria. Review, send.
The payer call is logged
The status-check call records caller, duration, and outcome on the task. The payer asks for more documents — a sub-task spawns for collection.
Resolved — or escalated, never lost
First-appeal resolution target is 65%. Anything aging out escalates with a full audit trail. The appeal window never closes silently.
Who benefits
Owns the denial queue with SLA compliance, escalations, and payer logs in one dashboard — and macros for the letters.
Co-signs, renewals, and PA decisions arrive in the same queue as everything else — one-click resolution from the chart or the queue.
Renewal processing under standing orders, referral follow-ups, and record collection for appeals — filtered to “my tasks only.”
Sees queue depth, aging, and productivity in real time; receives escalations before deadlines, not after write-offs.
Performance targets
The numbers this module is built to hit.
| Metric | Target |
|---|---|
| Denials creating a FHIR Task within 1 minute of posting | 100% |
| Tasks resolved within SLA | ≥ 95% |
| Outbound payer calls / emails / SMS logged on the task | 100% — zero tolerance |
| AI next-best-action acceptance | ≥ 60% |
| Appeal letters generated via macro | ≥ 70% |
| Auto-escalations accepted by the practice manager | ≥ 90% |
| Routed tasks accepted without reassignment | ≥ 85% |
| Full work-queue load time, any role | ≤ 2 seconds |
Standards & interoperability
A queue payers can talk to.
Because tasks are standard FHIR Task resources, the queue interoperates with CMS-0057-F payer APIs rather than living in a proprietary silo — prior-auth status and adjudication detail pull through the Provider Access API instead of a manual portal login.
Connected modules
Where the work comes from.
Revenue Cycle
Denials from 835 posting and claim-status changes create tasks automatically.
Module 07 →eRx & EPCS
Renewals, changes, ePA decisions, and EPCS co-sign requests land in the prescriber's queue.
Module 05 →Patient Portal
Inbound patient messages route to staff queues with SLA tracking on responses.
Module 08 →Nothing falls through. Ever.
SLA clocks, auto-escalation, and AI guidance on every piece of follow-up work.
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