The gate is the engine.
These are the levers.
Each tool hooks into the deterministic decision the way a payer workflow already does: appeal a denial, classify a root cause, surface a gate inside the EHR, pre-check eligibility.
BRIDGE — image evidence into the gate
The report hedged. Verum reads the image.
Dictated radiology reports hedge. "L5-S1 narrowing on imaging, etiology unclear." The deterministic gate pends on the documentation gap — surgical decompression authorization requires imaging-confirmed moderate-to-severe stenosis with documented etiology. Today, that pend triggers a 3-day round-trip for a clarifying read.
BRIDGE closes the loop. Inside /review, the UM reviewer clicks "Read this image with Verum · Vision". The AI surfaces structured findings in 3-8 seconds (warm). The reviewer attests the relevant ones and clicks Promote. The deterministic gate re-derives against an augmented fact bank — BRIDGE-extended rules now fire MET — and the verdict flips PEND → APPROVE. Append-only audit on the Decision; every promotion reversible via the existing revert chain. Downstream artifacts (appeal letter, SOAP note, decision-packet PDF) cite the AI-attested evidence inline with full reviewer attribution.
- ·Verum · Vision (MedGemma 4B foundation) reads attached imaging
- ·Reviewer-attested promotion into the deterministic policy gate
- ·BRIDGE-extended rules carry brass pills in the cited-rules list
- ·Appeal letter + SOAP note auto-cite evidence with full attribution
Appeal Generator
A denial that drafts its own rebuttal.
When the gate produces DENY, the appeal generator runs the same facts through a hybrid template — every failing rule earns a paragraph that quotes the verbatim policy text, the missing fact, and the clinical reasoning to overturn.
Multi-version drafts, operator signature capture, and per-payer statute injection (42 CFR § 405.940 for Medicare, ERISA § 503 for commercial, 42 CFR § 438.402 for Medicaid). The result is a 4-6 page letter signed and exportable as PDF.
- ·Hybrid scaffold — deterministic template + LLM advocacy slots
- ·Per-payer statutes (Medicare · Commercial · Medicaid)
- ·Multi-version revisions (3 drafts, sessionStorage-backed)
- ·Times-Roman PDF with non-Latin1 boundary sanitization
Denial Root-Cause Analyzer
Every denial maps to a category.
Six denial taxonomies. Forty-seven CARC codes catalogued with WPC verbatim text. Per-category overturn estimates anchored to publicly-cited rates (AMA · GAO · Premier).
Per-rule fail counts, per-payer breakdowns, mean overturn. The cohort dashboard surfaces systemic patterns from one-off denials — the difference between "fix this case" and "fix the policy interpretation."
- ·Six denial categories — clinical · documentation · administrative · etc.
- ·WPC CARC/RARC catalog (47 codes) with appeal applicability flags
- ·X12 835 generator + parser (ASC X12N 5010)
- ·Cohort dashboard: by-payer, by-procedure, top-cited rules
CDS Hooks Service
EHR-native policy gates.
Spec-compliant CDS Hooks 1.0 endpoint — discovery + invocation routes following Da Vinci CRD patterns. The same deterministic gate, surfaced inside an Epic or Cerner order-sign workflow.
Two services: prior-auth-prefetch (full evaluation on order-sign) and appropriate-use-criteria (ACR / Choosing Wisely guidance on order-select). Content-addressed cache returns sub-50ms on repeat invocations; JWT inspection logs caller iss/sub/aud/exp.
- ·CDS Hooks 1.0 spec at /cds-services
- ·Two registered services (order-sign + order-select)
- ·Content-addressed cache (sub-50ms hit · ~30s miss)
- ·FHIR PlanDefinition + Library Bundle export
Eligibility Pre-Check
Coverage before the order is placed.
X12 270 generation, 271 parsing. Synthesized coverage status, member cost-share, prior-PA signal, and approval-likelihood projection. Bridges into /demo, /extended-demo, /cds-test, and /simulator so a real workflow stays one click away.
Custom-case mode with paste-to-extract metadata (age, sex, CPT, dx, payer hints inferred by LLM). Bulk eligibility, recent-cases localStorage roll, and 4 destination bridges to thread state forward.
- ·X12 270 generator + 271 parser (EB_CODE_LABELS table)
- ·Coverage + cost-share + prior-PA signal
- ·Custom case mode with LLM metadata extraction
- ·Four destination bridges (/demo, /extended-demo, /cds-test, /simulator)
Four tools, one
workspace.
Every output the engine produces lives in a workspace surface that a medical director actually uses — activity feed, appeal lifecycle, denial cohort, operator override.
Cross-feature activity feed
- F114:32Appeal letter signedL-001 · Lumbar MRI · Medicare · v3 · 12 statutes
- F314:28CDS Hooks invocationprior-auth-prefetch · Epic order-sign · 47ms cached
- F214:15Denial root-cause analyzedCARC 50 · medical necessity · ~76% overturn likely
- F414:02Eligibility check bridged to /reviewSynthia M. · Lumbar MRI · CPT 72148 · Medicare Part B
- F113:48Appeal draft createdL-007 · denial overturn · 4 paragraphs · 12 citations
- F313:35CDS Hooks invocationappropriate-use-criteria · Cerner order-select · 1.4s
Appeal lifecycle
- DraftedF1 paragraphs · v3
- SignedOperator hand · MD-4187
- FiledEDI 277 · payer ack
- ResponseWithin 60d · Medicare
- OutcomeOverturned / upheld
Denial cohort dashboard
- Clinical rationale18 · 72% overturn
- Documentation insufficient14 · 62% overturn
- Medical necessity11 · 49% overturn
- Administrative7 · 81% overturn
- Authorization gap5 · 55% overturn
- Other3 · 33% overturn
- 01LCD-L34220-3.1conservativeTx ≥ 6w22fails
- 02LCD-L34220-3.2odi ≥ 3014fails
- 03AETNA-CPB-0236-4bredFlag bypass evaluated8fails
Operator-promote workflow
Hard fail · conservativeTx 5.0w below 6w threshold.
Click the override button to promote · audit retains both verdicts.
- 14:23:42engineEvaluated · DENY · confidence 0.88