Denial triage
A denial arrives. The agent reads it, classifies the payer's stated reason, and proposes a next action. It never acts and it never communicates the determination.
Never automated
An adverse determination is a clinical judgement. State law, CMS utilization-management rules and the FDA clinical-decision-support criteria all land on the same requirement, and the mask enforces it at every autonomy level.
#What it classifies
| Category | What it proposes | What it needs |
|---|---|---|
| insufficient documentation | A corrected resubmission with the missing clinical documentation | Clinical notes, a licensed human release |
| not medically necessary | A peer-to-peer review rather than a resubmission | A licensed clinician |
| investigational | Clinical review - a corrected resubmission will not change this | Supporting literature, peer-to-peer scheduling |
| benefit exclusion | Verify benefits; if excluded, an advance beneficiary notice conversation | Eligibility recheck, patient financial counselling |
| unclassified | Manual review | A licensed human - escalating rather than guessing is the correct behaviour |
#A denial with no reason is a payer exception
CMS-0057-F requires impacted payers to give a specific reason for a denial. The platform captures statusReasons[] on every adverse determination and treats an empty one as a reportable exception against the payer rather than a gap in our own data.