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Which client's claim was denied on December 18, 2023, by Pacific Health Alliance and what was the reason cited?

Gold answer

Client XY-303 was denied for lack of medical necessity.

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Input
721k
Output
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Steps
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Tools
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Latency
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Cost
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#1 Ran rg -n "Pacific Health Alliance|December 18, 2023|denied|claim" agent_memory 609,066 chars
Command command_execution 
rg -n "Pacific Health Alliance|December 18, 2023|denied|claim" agent_memory
Result 2 lines 
agent_memory/intake_templates/informed_consent_form_v2.1.md:230:*   **Payment:** Activities necessary to obtain payment for services. This includes submitting claims to insurance (if applicable), billing you directly, and engaging in collection efforts if necessary.
agent_memory/intake_templates/informed_consent_form_v2.1.md:242:*   **Workers' Compensation:** Disclosures related to workers' compen…
#1 Ran sed -n '268,296p' agent_memory/memory/reference/billing_codes_and_policies_guide.md 2,561 chars
Command command_execution 
sed -n '268,296p' agent_memory/memory/reference/billing_codes_and_policies_guide.md
Result 9 lines 
### 5.3. Case Study: PHA Denial `ref_claim_pha_202312_8451`

This is a real-world example of a denial we faced and how we handled it. Understanding this process is key to managing future denials effectively.

*   **Claim ID:** `ref_claim_pha_202312_8451`
*   **Client:** (Anonymized for this guide)
*   **Date of Service:** Late November 2023
*   **Payer:** Providence Health Alliance (PHA)
*   **CPT…
#1 Ran rg -n "ref_claim_pha_202312_8451|f465|Lack of Medical Necessity|Pacific Health Alliance|PHA" agent_memory/admin agent_memory/memory agent_me… 195,911 chars
Command command_execution 
rg -n "ref_claim_pha_202312_8451|f465|Lack of Medical Necessity|Pacific Health Alliance|PHA" agent_memory/admin agent_memory/memory agent_memory/clients
Result 2 lines 
agent_memory/admin/billing/insurance_correspondence/2024-01-26_pha_peer_review_request_xy303.md:4:Subject: Re: [External] Follow Up: Appeal of Claim Denial - Client XY303 - Policy Ref: ref_claim_pha_202312_8451
agent_memory/admin/billing/insurance_correspondence/2024-01-26_pha_peer_review_request_xy303.md:8:Thank you for your patience and for following up regarding the appeal for client ref_client…
#1 Ran sed -n '1,60p' agent_memory/admin/billing/insurance_correspondence/2024-01-26_pha_peer_review_request_xy303.md 4,916 chars
Command command_execution 
sed -n '1,60p' agent_memory/admin/billing/insurance_correspondence/2024-01-26_pha_peer_review_request_xy303.md
Result 8 lines 
From: clark.omalley@pacifichealthalliance.com
To: ben.carter@cypressgrovecounseling.com
Date: Fri, 26 Jan 2024 10:15:02 -0800
Subject: Re: [External] Follow Up: Appeal of Claim Denial - Client XY303 - Policy Ref: ref_claim_pha_202312_8451

Dear Mr. Carter,

Thank you for your patience and for following up regarding the appeal for client ref_client_xy303. I have reviewed the submitted documentation…
#1 Ran sed -n '1,120p' agent_memory/admin/billing/insurance_correspondence/2023-12-21_pha_appeal_submission_xy303.md 13,104 chars
Command command_execution 
sed -n '1,120p' agent_memory/admin/billing/insurance_correspondence/2023-12-21_pha_appeal_submission_xy303.md
Result 8 lines 
From: ben.carter@cypressgrovecounseling.com
To: clark.omalley@pacifichealthalliance.com
Date: Thu, 21 Dec 2023 10:05:17 -0800
Subject: Formal Appeal Submission - Claim PHA-202312-8451 - Client ID: xy303

Dear Mr. O'Malley,

Please accept this email and the attached formal letter as our submission for an appeal regarding the denial of services for claim number PHA-202312-8451, associated with clien…
#1 Ran /bin/zsh -lc 'rg -n "December 18[''^'"\\n]*(denial|denied)|denial["'^'"\\n]*December 18|denied["'^'"\\n]*December 18|reason|medical necessit… 6,227 chars
Command command_execution 
/bin/zsh -lc 'rg -n "December 18[''^'"\\n]*(denial|denied)|denial["'^'"\\n]*December 18|denied["'^'"\\n]*December 18|reason|medical necessity|threshold|expanded services\" agent_memory/admin/billing/insurance_correspondence/2023-12-21_pha_appeal_submission_xy303.md agent_memory/admin/billing/insurance_correspondence/2024-01-26_pha_peer_review_request_xy303.md"
Result 1 lines 
agent_memory/admin/billing/insurance_correspondence/2023-12-21_pha_appeal_submission_xy303.md:8:Please accept this email and the attached formal letter as our submission for an appeal regarding the denial of services for claim number PHA-202312-8451, associated with client ID xy303. We received notification of the denial on December 18th, 2023, and are formally requesting a review of this decision…
#1 Ran rg -n \"Pacific Health Alliance|December 18(th)?, 2023|December 18th, 2023|decision rendered on December 18|denial of services\" agent_memor… 47,221 chars
Command command_execution 
rg -n \"Pacific Health Alliance|December 18(th)?, 2023|December 18th, 2023|decision rendered on December 18|denial of services\" agent_memory/admin/billing/insurance_correspondence agent_memory/clients agent_memory/memory -g '*.md'
Result 2 lines 
agent_memory/admin/billing/insurance_correspondence/2024-01-26_pha_peer_review_request_xy303.md:8:Thank you for your patience and for following up regarding the appeal for client ref_client_xy303. I have reviewed the submitted documentation pertaining to claim ref_claim_pha_202312_8451 and the subsequent appeal filed on December 18, 2023.
agent_memory/admin/billing/insurance_correspondence/2024-01…
#1 Ran sed -n '1,80p' agent_memory/admin/billing/insurance_correspondence/2023-12-20_appeal_justification_xy303.md 4,546 chars
Command command_execution 
sed -n '1,80p' agent_memory/admin/billing/insurance_correspondence/2023-12-20_appeal_justification_xy303.md
Result 10 lines 
From: ben.carter@cypressgrovecounseling.com
To: maria.flores@cypressgrovecounseling.com
Date: Mon, 18 Dec 2023 15:32:10 -0800
Subject: FW: Claim Denial - Client XY-303 - Pacific Health Alliance

Maria,

Can you please provide a clinical justification for an appeal on this denial for client XY-303? The insurance company is citing lack of medical necessity for continued weekly sessions.

I've attach…
#1 Ran find agent_memory/clients -maxdepth 2 -type d | sed -n '1,160p' 3,347 chars
Command command_execution 
find agent_memory/clients -maxdepth 2 -type d | sed -n '1,160p'
Result 14 lines 
agent_memory/clients
agent_memory/clients/pq-307
agent_memory/clients/pq-307/admin
agent_memory/clients/rs-206
agent_memory/clients/rs-206/notes
agent_memory/clients/ef-102
agent_memory/clients/ef-102/admin
agent_memory/clients/ef-301
agent_memory/clients/ef-301/notes
agent_memory/clients/cd-202
agent_memory/clients/cd-202/admin
agent_memory/clients/kl-105
agent_memory/clients/kl-105/admin
agent_m…
#1 Ran rg -n \"XY-303|xy303|ref_client_xy303|Client ID: xy303|Client ID\\s*:\\s*XY-303\" agent_memory -g '*.md' 162,568 chars
Command command_execution 
rg -n \"XY-303|xy303|ref_client_xy303|Client ID: xy303|Client ID\\s*:\\s*XY-303\" agent_memory -g '*.md'
Result 2 lines 
agent_memory/admin/billing/insurance_correspondence/2024-01-26_pha_peer_review_request_xy303.md:8:Thank you for your patience and for following up regarding the appeal for client ref_client_xy303. I have reviewed the submitted documentation pertaining to claim ref_claim_pha_202312_8451 and the subsequent appeal filed on December 18, 2023.
agent_memory/admin/billing/insurance_correspondence/2024-01…
#1 Ran rg --files agent_memory/clients/xy-303 792 chars
Command command_execution 
rg --files agent_memory/clients/xy-303
Result 7 lines 
agent_memory/clients/xy-303/notes/2024-04-29_session_note.md
agent_memory/clients/xy-303/notes/2024-03-18_session_note.md
agent_memory/clients/xy-303/notes/2024-02-05_session_note.md
agent_memory/clients/xy-303/notes/2023-12-11_session_note.md
agent_memory/clients/xy-303/notes/2024-04-15_session_note.md
agent_memory/clients/xy-303/notes/2023-11-13_session_note.md
agent_memory/clients/xy-303/notes/…
#1 Ran rg -n \"Client Name|Name:|Client ID|ref_client_xy303|XY-303|xy303\" agent_memory/clients/xy-303 -g '*.md' 70,724 chars
Command command_execution 
rg -n \"Client Name|Name:|Client ID|ref_client_xy303|XY-303|xy303\" agent_memory/clients/xy-303 -g '*.md'
Result 2 lines 
agent_memory/clients/xy-303/notes/2024-01-22_session_note.md:5:*   **MRN:** XY-303
agent_memory/clients/xy-303/notes/2024-01-22_session_note.md:22:Pt (XY-303) reports feeling "stuck" this past week, particularly around their ability to complete tasks related to their job search. They described a recurring pattern of feeling overwhelmed by the prospect of applying for new positions, leading to proc…
#1 Ran sed -n '1,50p' agent_memory/clients/xy-303/admin/intake_form_2023-11-08.md 2,117 chars
Command command_execution 
sed -n '1,50p' agent_memory/clients/xy-303/admin/intake_form_2023-11-08.md
Result 15 lines 
# Client Intake Packet: XY-303

**Date Completed:** 2023-11-08
**Prepared By:** Ben Carter (Administrative & Billing Coordinator)
**Assigned Clinician:** Maria Flores, LMFT

---

## Table of Contents

1.  [Client Information](#client-information)
2.  [Demographics](#demographics)
3.  [Insurance Information](#insurance-information)
4.  [Presenting Concerns](#presenting-concerns)
5.  [Client History…
Answer
The denied claim was for **client XY-303** / `ref_client_xy303`. Pacific Health Alliance cited **lack of medical necessity**: the documentation did not sufficiently justify continued **weekly 60-minute psychotherapy sessions** under CPT `90837`, or show that the client’s condition required that frequency and duration at that time. Source: [2023-12-20_appeal_justification_xy303.md](/Users/prasanna/Documents/supermemoryai/supermemoryfs/.scratch/eval/eval/workspace/fs/dp_009/agent_memory/admin/bi…
Judge: covers all asked facts
SMFS Won View raw JSON
Input
146k
Output
2k
Steps
1
Tools
4
Latency
47.8s
Cost
$1.80
#1 Ran rg -n "Pacific Health Alliance|December 18, 2023|denied" . 238,652 chars
Command command_execution 
rg -n "Pacific Health Alliance|December 18, 2023|denied" .
Result 1 lines 
./admin/billing/insurance_correspondence/2023-12-18_pha_denial_xy303.md:9:This email is to formally notify you of a denial for the recent claim submitted for services rendered to patient identified as ref_client_xy303. The claim in question, reference number ref_claim_pha_202312_8451, pertains to psychotherapy services provided on multiple dates, specifically during the month of November. Followin…
#1 Ran smfs grep "claim denied on December 18 2023 by Pacific Health Alliance reason cited" 10,504 chars
Command command_execution 
smfs grep "claim denied on December 18 2023 by Pacific Health Alliance reason cited"
Result 5 lines 
# supermemory semantic search — 10 results for "claim denied on December 18 2023 by Pacific Health Alliance reason cited"
# searches by meaning across files in this container. usage:
#   grep "natural language query"          search all files
#   grep "query" path/to/dir/              search within directory
# output: <filepath>:<line_start>-<line_end>:<chunk> (chunk text is verbatim from the file…
#1 Ran nl -ba admin/billing/insurance_correspondence/2023-12-18_pha_denial_xy303.md | sed -n '1,80p' 8,238 chars
Command command_execution 
nl -ba admin/billing/insurance_correspondence/2023-12-18_pha_denial_xy303.md | sed -n '1,80p'
Result 9 lines 
     1	From: clark.omalley@pacifichealthalliance.com
     2	To: ben.carter@cypressgrovecounseling.com
     3	Cc: maria.flores@cypressgrovecounseling.com
     4	Date: Mon, 18 Dec 2023 09:15:32 -0800
     5	Subject: Claim Denial - Patient ID XY303 - Claim Ref # 202312_8451
     6	
     7	Dear Mr. Carter,
     8	
     9	This email is to formally notify you of a denial for the recent claim submitted f…
#1 Ran nl -ba staff/notes/2023-12-18_internal_fwd_pha_denial_xy303.md | sed -n '20,50p;80,95p' 6,831 chars
Command command_execution 
nl -ba staff/notes/2023-12-18_internal_fwd_pha_denial_xy303.md | sed -n '20,50p;80,95p'
Result 11 lines 
    20	**Date:** December 18, 2023
    21	
    22	**Re:** Claim Determination Notice
    23	**Claim Number:** PHA-202312-8451
    24	**Client Identification Number:** XY-303
    25	**Date(s) of Service:** Various dates in November 2023
    26	**Provider:** Cypress Grove Counseling
    27	
    28	Dear Provider,
    29	
    30	This correspondence serves as formal notification regarding the adjudicat…
Answer
Pacific Health Alliance denied the claim for client `XY-303` (`ref_client_xy303`), claim `ref_claim_pha_202312_8451`. The reason cited was that the CPT `90837` psychotherapy services did not meet PHA’s medical-necessity criteria: the documentation was considered insufficient to justify the ongoing weekly 60-minute session frequency/duration for the client’s condition. See [2023-12-18_pha_denial_xy303.md](/Users/prasanna/Documents/supermemoryai/supermemoryfs/.scratch/eval/eval/workspace/smfs/dp_…
Judge: covers all asked facts