AI Claims Adjudication Agent

How Cassidy automates this using AI

Step 1: Trigger on incoming 837 claim

The Workflow activates when a new EDI 837 (professional, institutional, or dental) arrives via clearinghouse, web portal, or OCR-converted paper submission automatically generating TA1/999/277CA acknowledgements.

Step 2: Validate and normalize claim data

Cassidy runs SNIP-level validations, checks member eligibility via 270/271, confirms provider NPI and network status, and flags duplicates or missing data before the claim proceeds.

Step 3: Apply repricing and COB logic

Cassidy routes claims to PPO repricing APIs, applies fee schedules (RBRVS, DRG/APC), determines primary payer status, and calculates allowed amounts using COB rules and plan-specific pricing.

Step 4: Execute clinical and coding edits

The Workflow applies NCCI/MUE edits, diagnosis-procedure compatibility checks, prior authorization cross-references, and medical necessity policies automatically adjusting or flagging claims that fail.

Step 5: Determine benefit and adjudicate

Cassidy interprets plan documents to apply deductibles, coinsurance, copays, and accumulators then classifies each claim as auto-pay, deny, or pend with the appropriate CARC/RARC codes.

Step 6: Route exceptions with Human-in-the-Loop

Complex pends COB chases, attachment requests, clinical reviews are routed to the right work queue with pre-assembled context, keeping examiners focused on decisions rather than data gathering.

Step 7: Generate 835 ERA and remittance

Cassidy produces compliant 835 remittance advice, member EOBs, and provider EOPs with full payment traceability, then triggers EFT instructions and reconciliation data for downstream posting.