{ "slug": "dp_009-q05-claude", "dp": "dp_009", "files": 480, "qid": "q05", "family": "multi_hop", "prompt": "Which client's claim was denied on December 18, 2023, by Pacific Health Alliance and what was the reason cited?", "gold": "Client XY-303 was denied for lack of medical necessity.", "agent": "claude", "fs": { "agent": "claude", "success": true, "steps": 15, "inputTokens": 574385, "outputTokens": 644, "totalTokens": 575029, "cost": 8.6641, "durationMs": 48690, "answer": "**Client:** Patient ID **XY-303** (Cypress Grove Counseling client; assigned clinician Maria Flores, LCSW). The actual name is redacted for privacy in the intake records \u2014 XY-303 is the identifier used throughout the billing and clinical files.\n\n**Denial date/source:** December 18, 2023, by Clark O'Malley, Claims Adjuster at Pacific Health Alliance (claim ref `202312_8451`).\n\n**Reason cited:** Lack of **medical necessity** for the services billed under CPT code **90837** (Psychotherapy, 60 minutes) on November 6, 13, 20, and 27, 2023. PHA's clinical review concluded that the submitted documentation did not sufficiently justify the **frequency and intensity** (weekly 60-minute sessions) of treatment \u2014 i.e., it failed to demonstrate symptom severity and functional impairment warranting that level of care, per PHA Policy \u00a72.4.1.b (Medical Necessity Criteria for Mental Health Services), \u00a73.1.c (Documentation Requirements for Outpatient Psychotherapy), and Internal Review Guideline M-112.\n\nSource: `agent_memory/admin/billing/insurance_correspondence/2023-12-18_pha_denial_xy303.md`.", "judgeReason": "covers all asked facts", "toolCalls": 9, "trajectory": [ { "step": 1, "inputTokens": 27986, "outputTokens": 8, "text": "", "toolCalls": [] }, { "step": 2, "inputTokens": 27986, "outputTokens": 8, "text": "", "toolCalls": [ { "name": "Bash", "input": "{\"command\": \"ls /Users/prasanna/Documents/supermemoryai/supermemoryfs/.scratch/eval/eval/workspace/fs/dp_009/agent_memory/\", \"description\": \"List agent_memory directory\"}", "outputPreview": "admin\nce_reading\nclients\nintake_templates\nmemory\nstaff", "outputChars": 54 } ] }, { "step": 3, "inputTokens": 28231, "outputTokens": 66, "text": "", "toolCalls": [ { "name": "Grep", "input": "{\"pattern\": \"Pacific Health Alliance\", \"path\": \"/Users/prasanna/Documents/supermemoryai/supermemoryfs/.scratch/eval/eval/workspace/fs/dp_009/agent_memory/\", \"output_mode\": \"files_with_matches\"}", "outputPreview": "Found 17 files\nagent_memory/staff/notes/2023-12-18_internal_fwd_pha_denial_xy303.md\nagent_memory/staff/notes/2023-12-19_clinical_justification_xy303.md\nagent_memory/staff/notes/2024-03-25_email_q1_billing_summary_issues.md\nagent_memory/admin/billing/insurance_correspondence/2024-01-26_pha_peer_review_request_xy303.md\nagent_memory/admin/billing/insurance_correspondence/2023-12-05_credentialing_rfi_\u2026", "outputChars": 1465 } ] }, { "step": 4, "inputTokens": 28231, "outputTokens": 66, "text": "", "toolCalls": [ { "name": "Grep", "input": "{\"pattern\": \"2023-12-18|December 18, 2023|12/18/2023\", \"path\": \"/Users/prasanna/Documents/supermemoryai/supermemoryfs/.scratch/eval/eval/workspace/fs/dp_009/agent_memory/\", \"output_mode\": \"files_with_matches\"}", "outputPreview": "Found 9 files\nagent_memory/staff/notes/2023-12-18_internal_fwd_pha_denial_xy303.md\nagent_memory/admin/billing/insurance_correspondence/2024-01-26_pha_peer_review_request_xy303.md\nagent_memory/admin/billing/insurance_correspondence/2023-12-20_appeal_justification_xy303.md\nagent_memory/admin/billing/insurance_correspondence/2023-12-21_pha_appeal_submission_xy303.md\nagent_memory/clients/ij-102/notes/\u2026", "outputChars": 669 } ] }, { "step": 5, "inputTokens": 29763, "outputTokens": 59, "text": "", "toolCalls": [ { "name": "Read", "input": "{\"file_path\": \"/Users/prasanna/Documents/supermemoryai/supermemoryfs/.scratch/eval/eval/workspace/fs/dp_009/agent_memory/admin/billing/insurance_correspondence/2023-12-18_pha_denial_xy303.md\"}", "outputPreview": "1\tFrom: clark.omalley@pacifichealthalliance.com\n2\tTo: ben.carter@cypressgrovecounseling.com\n3\tCc: maria.flores@cypressgrovecounseling.com\n4\tDate: Mon, 18 Dec 2023 09:15:32 -0800\n5\tSubject: Claim Denial - Patient ID XY303 - Claim Ref # 202312_8451\n6\t\n7\tDear Mr. Carter,\n8\t\n9\tThis email is to formally notify you of a denial for the recent claim submitted for services rendered to patient identified as\u2026", "outputChars": 33075 } ] }, { "step": 6, "inputTokens": 41737, "outputTokens": 34, "text": "", "toolCalls": [] }, { "step": 7, "inputTokens": 41737, "outputTokens": 34, "text": "The patient ID is `xy303`. Let me identify which client this maps to.", "toolCalls": [] }, { "step": 8, "inputTokens": 41737, "outputTokens": 34, "text": "", "toolCalls": [ { "name": "Grep", "input": "{\"pattern\": \"xy303|XY303\", \"path\": \"/Users/prasanna/Documents/supermemoryai/supermemoryfs/.scratch/eval/eval/workspace/fs/dp_009/agent_memory/clients/\", \"output_mode\": \"files_with_matches\"}", "outputPreview": "Found 11 files\nagent_memory/clients/xy-303/notes/2024-04-29_session_note.md\nagent_memory/clients/xy-303/notes/2024-03-18_session_note.md\nagent_memory/clients/xy-303/notes/2024-02-05_session_note.md\nagent_memory/clients/xy-303/notes/2023-12-11_session_note.md\nagent_memory/clients/xy-303/notes/2024-04-15_session_note.md\nagent_memory/clients/xy-303/notes/2024-04-01_session_note.md\nagent_memory/client\u2026", "outputChars": 684 } ] }, { "step": 9, "inputTokens": 41737, "outputTokens": 34, "text": "", "toolCalls": [ { "name": "Bash", "input": "{\"command\": \"ls /Users/prasanna/Documents/supermemoryai/supermemoryfs/.scratch/eval/eval/workspace/fs/dp_009/agent_memory/clients/\", \"description\": \"List client directories\"}", "outputPreview": "aa-206\nab-101\nbc-207\nbc-406\ncd-202\nde-208\nef-102\nef-301\nfg-301\ngh-103\ngh-402\nhi-302\nij-102\nij-104\nij-304\nij-403\nij-501\nij-505\njk-304\nkl-102\nkl-105\nkl-304\nkl-403\nkl-601\nkl-602\nkl-606\nlm-305\nmn-102\nmn-106\nmn-505\nmn-701\nmn-703\nmn-707\nno-306\nop-107\nop-606\npq-106\npq-307\nqr-108\nqr-707\nrs-206\nrs-308\nst-201\ntu-306\ntu-401\nuv-203\nvw-403\nwx-204\nxy-303\nxy-404\nyz-205\nza-405", "outputChars": 363 } ] }, { "step": 10, "inputTokens": 42768, "outputTokens": 59, "text": "", "toolCalls": [ { "name": "Read", "input": "{\"file_path\": \"/Users/prasanna/Documents/supermemoryai/supermemoryfs/.scratch/eval/eval/workspace/fs/dp_009/agent_memory/clients/xy-303/admin/intake_form_2023-11-08.md\", \"limit\": 30}", "outputPreview": "1\t# Client Intake Packet: XY-303\n2\t\n3\t**Date Completed:** 2023-11-08\n4\t**Prepared By:** Ben Carter (Administrative & Billing Coordinator)\n5\t**Assigned Clinician:** Maria Flores, LMFT\n6\t\n7\t---\n8\t\n9\t## Table of Contents\n10\t\n11\t1. [Client Information](#client-information)\n12\t2. [Demographics](#demographics)\n13\t3. [Insurance Information](#insurance-information)\n14\t4. [Presenting Concerns](#present\u2026", "outputChars": 1275 } ] }, { "step": 11, "inputTokens": 43506, "outputTokens": 50, "text": "", "toolCalls": [ { "name": "Grep", "input": "{\"pattern\": \"Name|name:|Client Name|Full Name\", \"path\": \"/Users/prasanna/Documents/supermemoryai/supermemoryfs/.scratch/eval/eval/workspace/fs/dp_009/agent_memory/clients/xy-303/admin/intake_form_2023-11-08.md\", \"output_mode\": \"content\", \"-n\": true, \"head_limit\": 20}", "outputPreview": "34:Client Name: [REDACTED FOR PRIVACY]\n64:* **Subscriber Name:** [REDACTED FOR PRIVACY] (Client's Spouse)\n310:**Client Name (Printed):** ________________________________________\n340:Hi Maria and [Your Name],\n351:**From:** [Your Name] \n360:[Your Name]\n370:**Dear [Client Name],**\n396:[Your Name]", "outputChars": 330 } ] }, { "step": 12, "inputTokens": 43929, "outputTokens": 49, "text": "", "toolCalls": [] }, { "step": 13, "inputTokens": 43929, "outputTokens": 49, "text": "", "toolCalls": [ { "name": "Grep", "input": "{\"pattern\": \"xy.?303|XY.?303|ref_client_xy303\", \"path\": \"/Users/prasanna/Documents/supermemoryai/supermemoryfs/.scratch/eval/eval/workspace/fs/dp_009/agent_memory/\", \"output_mode\": \"files_with_matches\"}", "outputPreview": "Found 37 files\nagent_memory/staff/notes/2023-12-18_internal_fwd_pha_denial_xy303.md\nagent_memory/staff/notes/2023-12-19_clinical_justification_xy303.md\nagent_memory/admin/billing/insurance_correspondence/2024-01-26_pha_peer_review_request_xy303.md\nagent_memory/admin/billing/insurance_correspondence/2024-01-25_pha_appeal_followup_xy303.md\nagent_memory/admin/billing/insurance_correspondence/2023-12-\u2026", "outputChars": 2515 } ] }, { "step": 14, "inputTokens": 45554, "outputTokens": 47, "text": "", "toolCalls": [] }, { "step": 15, "inputTokens": 45554, "outputTokens": 47, "text": "**Client:** Patient ID **XY-303** (Cypress Grove Counseling client; assigned clinician Maria Flores, LCSW). The actual name is redacted for privacy in the intake records \u2014 XY-303 is the identifier used throughout the billing and clinical files.\n\n**Denial date/source:** December 18, 2023, by Clark O'Malley, Claims Adjuster at Pacific Health Alliance (claim ref `202312_8451`).\n\n**Reason cited:** Lack of **medical necessity** for the services billed under CPT code **90837** (Psychotherapy, 60 minutes) on November 6, 13, 20, and 27, 2023. PHA's clinical review concluded that the submitted documentation did not sufficiently justify the **frequency and intensity** (weekly 60-minute sessions) of treatment \u2014 i.e., it failed to demonstrate symptom severity and functional impairment warranting that level of care, per PHA Policy \u00a72.4.1.b (Medical Necessity Criteria for Mental Health Services), \u00a73.1.c (Documentation Requirements for Outpatient Psychotherapy), and Internal Review Guideline M-112.\n\nSource: `agent_memory/admin/billing/insurance_correspondence/2023-12-18_pha_denial_xy303.md`.", "toolCalls": [] } ] }, "smfs": { "agent": "claude", "success": true, "steps": 3, "inputTokens": 96227, "outputTokens": 1, "totalTokens": 96228, "cost": 1.4435, "durationMs": 8353, "answer": "The client whose claim was denied on December 18, 2023, by Pacific Health Alliance was **client ID XY-303** (treated at Cypress Grove Counseling).\n\n- **Claim:** PHA-202312-8451 (CPT code 90837, sessions in November 2023 for MDD)\n- **Reason cited:** Reason Code 507 \u2014 **\"Medical Necessity Not Established\"** \u2014 citing policy section 4.7.B; PHA determined the services billed under CPT 90837 did not meet medical necessity criteria under the member's benefit plan.", "judgeReason": "covers all asked facts", "toolCalls": 1, "trajectory": [ { "step": 1, "inputTokens": 30792, "outputTokens": 0, "text": "", "toolCalls": [] }, { "step": 2, "inputTokens": 30792, "outputTokens": 0, "text": "", "toolCalls": [ { "name": "Bash", "input": "{\"command\": \"smfs grep \\\"Pacific Health Alliance claim denied December 18 2023\\\" /Users/prasanna/Documents/supermemoryai/supermemoryfs/.scratch/eval/eval/workspace/smfs/dp_009/agent_memory/\", \"description\": \"Search agent memory for Pacific Health Alliance denial\"}", "outputPreview": "# supermemory semantic search \u2014 10 results for \"Pacific Health Alliance claim denied December 18 2023\"\n# searches by meaning across files in this container. usage:\n# grep \"natural language query\" search all files\n# grep \"query\" path/to/dir/ search within directory\n# output: :-: (chunk text is verbatim from the file)\n\n/staff/notes/202\u2026", "outputChars": 10677 } ] }, { "step": 3, "inputTokens": 34643, "outputTokens": 1, "text": "The client whose claim was denied on December 18, 2023, by Pacific Health Alliance was **client ID XY-303** (treated at Cypress Grove Counseling).\n\n- **Claim:** PHA-202312-8451 (CPT code 90837, sessions in November 2023 for MDD)\n- **Reason cited:** Reason Code 507 \u2014 **\"Medical Necessity Not Established\"** \u2014 citing policy section 4.7.B; PHA determined the services billed under CPT 90837 did not meet medical necessity criteria under the member's benefit plan.", "toolCalls": [] } ] } }