{
"output": {
"claim_id": "58ba229f-b35c-4e46-9af5-e54df39b6e48",
"optimizer_run_id": "ba757342-2a29-4972-ab3a-341a04a4bd9b",
"ai_generated_claim_extended": "Deprecated",
"ai_generated_encounter_description": "**Claim Summary**\n\n**Complete Encounter Description:**\nThe provided FHIR Claim resource details a professional service encounter for a patient diagnosed with Obesity, class 1 (E66.811) and Other specified anxiety disorders (F41.8). A CPT code 99214 with modifier RT was performed on November 17, 2025, with a charge of $150.00. The claim indicates that the provider accepts assignment. No further clinical narrative or treatment details are explicitly stated in the provided notes.\n\n**Patient Information:**\n* Name: Jane Doe\n* DOB: 10-10-1970\n* Gender: male\n* Address: 891 Cedar Street, Minneapolis, MN 55401\n* Patient ID/Account Number: OV7444602\n\n**Insurance Information:**\n* Primary Insurance Provider: Aetna\n* Payer ID/EDI Number: 60054\n* Insurance Plan: Not specified in notes.\n* Subscriber Name: Jane Doe\n* Subscriber ID: OV7444602\n* Group Number: OV7444602\n* Relationship to Subscriber: Self\n* Claim Filing Indicator Code: CI (Commercial Insurance Co.)\n\n**Billing Provider Information:**\n* Name: Chicago Healthcare Alliance\n* NPI: 2538929880\n* Tax ID: 52-6769967\n* Address: 221 North LaSalle Street, Chicago, IL 60601\n* Contact: Not specified in notes.\n* Taxonomy Code: 282N00000X\n\n**Rendering Provider Information:**\n* Name: Ethan Wilson\n* NPI: 1995116984\n* Taxonomy Code: 208D00000X\n\n**Submitter Information:**\n* Name: Not specified in notes.\n* ID: Not specified in notes.\n* Contact: Not specified in notes.\n\n**Service Information:**\n* Date of Service: 11-17-2025\n* Place of Service: Not specified in notes.\n* Procedures:\n * 99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Typically, 25 minutes are spent face-to-face with the patient and/or family.\n * Modifier: RT (Right side)\n* Diagnoses:\n * E66.811 - Obesity, class 1\n * F41.8 - Other specified anxiety disorders\n* Charges: $150.00\n* Service Units: 1\n* Diagnosis Pointers: 1, 2 (Both diagnoses apply to the procedure)\n\n**Claim Details:**\n* Assignment of Benefits: Not specified in notes.\n* Accept Assignment: Yes\n* Release of Information: Not specified in notes.\n* Provider Signature on File: Not specified in notes.\n* Prior Authorization Numbers: Not specified in notes.\n* Referral Number: Not specified in notes.\n* Special Billing Notes: Not specified in notes.\n* Related to: Not specified in notes.\n\n**Missing Information:**\n* Insurance Plan\n* Billing Provider Contact\n* Submitter Name\n* Submitter ID\n* Submitter Contact\n* Place of Service\n* Assignment of Benefits\n* Release of Information\n* Provider Signature on File\n* Prior Authorization Numbers\n* Referral Number\n* Special Billing Notes\n* Related to (Employment, Auto Accident, Other Accident)",
"ai_generated_x12_837": "{\n \"resourceType\": \"Claim\",\n \"id\": \"58ba229f-b35c-4e46-9af5-e54df39b6e48\",\n \"status\": \"active\",\n \"type\": {\n \"coding\": [\n {\n \"code\": \"professional\",\n \"system\": \"http://terminology.hl7.org/CodeSystem/claim-type\"\n }\n ]\n },\n \"patient\": {\n \"type\": \"Patient\",\n \"reference\": \"Patient/79c87bbd-9de4-41bb-a25f-0f78bfb41c4c\"\n },\n \"use\": \"claim\",\n \"created\": \"2025-11-21\",\n \"insurer\": {\n \"type\": \"Organization\",\n \"reference\": \"Organization/c9060e87-15c0-4b82-8a7d-f0faee2d456d\"\n },\n \"provider\": {\n \"type\": \"Organization\",\n \"reference\": \"Organization/7e294528-4edb-40df-ad50-9da07d05d195\"\n },\n \"priority\": {\n \"coding\": [\n {\n \"code\": \"normal\",\n \"system\": \"http://terminology.hl7.org/CodeSystem/processpriority\",\n \"display\": \"Normal\"\n }\n ]\n },\n \"supportingInfo\": [\n {\n \"code\": {\n \"coding\": [\n {\n \"code\": \"Y\",\n \"system\": \"https://bluebutton.cms.gov/assets/ig/CodeSystem-asgmntcd\",\n \"display\": \"Yes\"\n }\n ]\n },\n \"category\": {\n \"coding\": [\n {\n \"code\": \"acceptassignment\",\n \"system\": \"http://terminology.hl7.org/CodeSystem/claiminformationcategory\",\n \"display\": \"Accept Assignment\"\n }\n ]\n },\n \"sequence\": 1\n },\n {\n \"code\": {\n \"coding\": [\n {\n \"code\": \"CI\",\n \"system\": \"https://x12.org/codes/claim-filing-indicator-code\",\n \"display\": \"Commercial Insurance Co.\"\n }\n ]\n },\n \"category\": {\n \"coding\": [\n {\n \"code\": \"claim-filing-indicator\",\n \"system\": \"https://fhir.cairhealth.com/fhir/CodeSystem/claim-additional-information-category\",\n \"display\": \"Claim Filing Indicator Code\"\n }\n ]\n },\n \"sequence\": 2\n }\n ],\n \"careTeam\": [\n {\n \"sequence\": 1,\n \"provider\": {\n \"type\": \"Organization\",\n \"reference\": \"Organization/7e294528-4edb-40df-ad50-9da07d05d195\"\n },\n \"role\": {\n \"coding\": [\n {\n \"code\": \"primary\",\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"display\": \"Billing Provider\"\n }\n ]\n },\n \"responsible\": true,\n \"qualification\": {\n \"coding\": [\n {\n \"code\": \"282N00000X\",\n \"system\": \"http://nucc.org/provider-taxonomy\",\n \"display\": \"General Acute Care Hospital\"\n }\n ]\n }\n },\n {\n \"sequence\": 2,\n \"provider\": {\n \"type\": \"Practitioner\",\n \"reference\": \"Practitioner/95a40f30-9bf2-4030-ad46-b655a654d33a\"\n },\n \"role\": {\n \"coding\": [\n {\n \"code\": \"rendering\",\n \"system\": \"http://terminology.hl7.org/CodeSystem/claimcareteamrole\",\n \"display\": \"Rendering Provider\"\n }\n ]\n },\n \"responsible\": false,\n \"qualification\": {\n \"coding\": [\n {\n \"code\": \"208D00000X\",\n \"system\": \"http://nucc.org/provider-taxonomy\",\n \"display\": \"General Practice Physician\"\n }\n ]\n }\n }\n ],\n \"diagnosis\": [\n {\n \"sequence\": 1,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"code\": \"E66.811\",\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"display\": \"Obesity, class 1\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"code\": \"principal\",\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-diagnosistype\"\n }\n ]\n }\n ]\n },\n {\n \"sequence\": 2,\n \"diagnosisCodeableConcept\": {\n \"coding\": [\n {\n \"code\": \"F41.8\",\n \"system\": \"http://hl7.org/fhir/sid/icd-10-cm\",\n \"display\": \"Other specified anxiety disorders\"\n }\n ]\n },\n \"type\": [\n {\n \"coding\": [\n {\n \"code\": \"secondary\",\n \"system\": \"http://terminology.hl7.org/CodeSystem/ex-diagnosistype\"\n }\n ]\n }\n ]\n }\n ],\n \"insurance\": [\n {\n \"coverage\": {\n \"type\": \"Coverage\",\n \"reference\": \"Coverage/c81bb743-734c-4663-81b5-34329058cfb7\"\n },\n \"focal\": true,\n \"sequence\": 1\n }\n ],\n \"item\": [\n {\n \"sequence\": 1,\n \"careTeamSequence\": [\n 2\n ],\n \"diagnosisSequence\": [\n 1,\n 2\n ],\n \"productOrService\": {\n \"coding\": [\n {\n \"code\": \"99214\",\n \"system\": \"http://www.ama-assn.org/go/cpt\"\n }\n ]\n },\n \"modifier\": [\n {\n \"coding\": [\n {\n \"code\": \"RT\",\n \"system\": \"https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets\",\n \"display\": \"Right side\"\n }\n ]\n }\n ],\n \"servicedDate\": \"2025-11-17\",\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd/",\n \"code\": \"11\",\n \"display\": \"Office\"\n }\n ]\n },\n \"quantity\": {\n \"value\": 1\n },\n \"unitPrice\": {\n \"value\": 150.0,\n \"currency\": \"USD\"\n },\n \"net\": {\n \"value\": 150.0,\n \"currency\": \"USD\"\n }\n },\n {\n \"sequence\": 2,\n \"careTeamSequence\": [\n 2\n ],\n \"diagnosisSequence\": [\n 1\n ],\n \"productOrService\": {\n \"coding\": [\n {\n \"code\": \"3008F\",\n \"system\": \"http://www.ama-assn.org/go/cpt\"\n }\n ]\n },\n \"servicedDate\": \"2025-11-17\",\n \"locationCodeableConcept\": {\n \"coding\": [\n {\n \"system\": \"https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd/",\n \"code\": \"11\",\n \"display\": \"Office\"\n }\n ]\n },\n \"quantity\": {\n \"value\": 1\n },\n \"unitPrice\": {\n \"value\": 75.0,\n \"currency\": \"USD\"\n },\n \"net\": {\n \"value\": 75.0,\n \"currency\": \"USD\"\n }\n }\n ],\n \"total\": {\n \"value\": 225.0,\n \"currency\": \"USD\"\n },\n \"identifier\": [\n {\n \"value\": \"52343746129383\",\n \"system\": \"https://fhir.cairhealth.com/fhir/identifier/claim-id\",\n \"assigner\": {\n \"type\": \"Organization\",\n \"reference\": \"Organization/7e294528-4edb-40df-ad50-9da07d05d195\"\n }\n }\n ],\n \"extension\": [\n {\n \"url\": \"https://fhir.cairhealth.com/StructureDefinition/claim-patient-paid\",\n \"valueMoney\": {\n \"value\": 0,\n \"currency\": \"USD\"\n }\n }\n ],\n \"meta\": {\n \"extension\": [\n {\n \"url\": \"https://aidbox.app/tenant-organization-id\",\n \"valueReference\": {\n \"reference\": \"Organization/cair-health\"\n }\n },\n {\n \"url\": \"https://aidbox.app/ex/createdAt\",\n \"valueInstant\": \"2025-12-19T15:43:39.855972Z\"\n }\n ],\n \"lastUpdated\": \"2025-12-19T15:43:39.855972Z\",\n \"versionId\": \"16515281\"\n }\n}",
"relevant_rules_report": "{\n \"rules_flagged\": [],\n \"rules_applied\": [\n {\n \"id\": \"35924ec9-d150-4955-852f-4773b92243ad\",\n \"text\": \"If the patient is diagnosed with Obesity (any diagnosis code with (EXX), add service line item 3008F with 1 unit and a cost of 75.00\",\n \"tags\": \"\"\n },\n {\n \"id\": \"c0327e2a-4cbc-43c9-9571-9de5fb3419d7\",\n \"text\": \"All Aetna claims should be billed with place of service code 11\",\n \"tags\": null\n }\n ]\n}",
"edits": [
{
"difference": "The patient, coverage, insurer, provider, and care team elements in the generated claim are represented as references, while the uploaded claim included full resource objects for these elements.",
"rationale": "The system instructions explicitly require that these elements be represented as references only, omitting the full resource details, to ensure compliance with FHIR schema for references."
},
{
"difference": "The second diagnosis's sequence was changed from 1 to 2.",
"rationale": "Diagnosis sequence numbers must be unique for each diagnosis entry."
},
{
"difference": "The type of the second diagnosis (F41.8) was changed from 'principal' to 'secondary'.",
"rationale": "Typically, a claim should only have one principal diagnosis. The second diagnosis was reclassified as secondary."
},
{
"difference": "A second service line item was added to the claim.",
"rationale": "The rule \"If the patient is diagnosed with Obesity (any diagnosis code with (EXX), add service line item 3008F with 1 unit and a cost of 75.00\" and the enforcement criteria explicitly required the inclusion of procedure code 3008F for the patient's obesity diagnosis."
}
],
"additional_info": {
"organization_id": "ca12ca12-f9e0-4467-b55f-78874bd1468e",
"user_id": "ca12ca12-f9e0-4467-b55f-78874bd1468e",
"custom_guidelines": "",
"eligibility_check_info": ""
}
}
}
