ClaimJumper uses GPT-5.6 Sol to decide the correct resolution path for each denied service line on a remittance. That decision is called a lane and it drives everything that comes next: what artifact (if any) the tool produces, whether the billing team can approve and export it, and what manual steps they must perform. Every line is assigned exactly one lane before the pipeline moves on to prioritization and drafting.Documentation Index
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The five lanes
appeal — Cited draft appeal letter body
appeal — Cited draft appeal letter body
What it meansThe denial is clinically or procedurally disputable through the payer’s formal reconsideration process. Common triggers include a medical-necessity determination the provider believes is incorrect, a timely-filing denial where clearinghouse acknowledgment evidence exists, or a coverage decision tied to a specific LCD.What triggers this laneGPT-5.6 Sol reads the Group Code, CARC, and RARC together. Lanes such as the following are typical appeal candidates:
CO / CARC 50 / RARC N115— medical necessity denied against LCD criteriaCO / CARC 29— timely-filing denial with available submission evidence
corrected_claim — Cited corrected-claim worklist
corrected_claim — Cited corrected-claim worklist
What it meansThe denial was caused by missing or incorrect information in the original claim submission. The line should be corrected and resubmitted rather than formally appealed. Attempting an appeal on a correctable claim wastes a reconsideration opportunity.What triggers this laneMissing-information denials are the canonical trigger. For example:
CO / CARC 16 / RARC M51— claim/service lacks information needed for adjudication; the RARC names the specific missing element
patient_bill — Disposition only
patient_bill — Disposition only
What it meansThe service line carries a Patient Responsibility (
PR) group code, meaning the amount has been calculated as patient cost-share (deductible, coinsurance, or copay) rather than a provider write-off or a disputable denial.What triggers this lanePR group codes route here by default unless a RARC contradicts the patient-responsibility assignment. The billing team then follows their organization’s patient-billing policy.What ClaimJumper producesDisposition only — no generated letter. The queue shows the lane and the triage rationale, but no draft artifact is created.What the billing team does nextVerify patient responsibility and follow the organization’s patient-billing policy for issuing a statement or applying it to the patient’s account.Approvable and exportable? ❌ No — patient-bill lines cannot be approved or exported.write_off — Disposition only
write_off — Disposition only
What it meansThe denial represents an amount the provider cannot recover and has no practical basis to dispute — for example, a contractual adjustment already reflected in the allowed amount.What triggers this laneGPT-5.6 Sol determines that neither an appeal nor a corrected-claim resubmission is viable and the amount must be adjusted off the account. Recovery probability is typically very low.What ClaimJumper producesDisposition only — no generated letter. The queue shows the lane and the triage rationale.What the billing team does nextObtain the required internal approval and follow the organization’s adjustment policy before posting the write-off.Approvable and exportable? ❌ No — write-off lines cannot be approved or exported.
CARC 197 denials can never be automatically written off. Because CARC 197 is a payer-responsibility denial, abandoning that revenue requires a deliberate human decision. The invariant escalates these lines to
human_review. See Safety Invariants.human_review — Deterministic safety brief
human_review — Deterministic safety brief
What it meansOne or more safety invariants fired after the model’s initial lane decision, or the model’s routing confidence fell below the automation threshold. The line cannot be handled automatically and needs a human to decide the next action.What triggers this laneThe three code-enforced invariants each escalate to
human_review:COgroup code with a model-suggestedpatient_billlane- CARC
197with a model-suggestedwrite_offlane - Model confidence below
0.6
Lane decision model
GPT-5.6 Sol acts as a healthcare reimbursement specialist for triage. It receives a structuredAdjustmentLine object — group code, CARC, RARC, billed amount, description, notice date, and any notes — and produces a structured TriageModelOutput object. Critically, the model reads Group Code + CARC + RARC together, never a CARC in isolation.
The output schema contains six fields:
| Field | Type | Description |
|---|---|---|
lane | enum | One of the five routing lanes |
root_cause | string | The specific denial category driving the decision |
rationale | string | Explanation citing the Group Code / CARC / RARC that drove the decision |
evidence_needed | string[] | What the biller must attach for the recommended lane to succeed |
confidence | number (0–1) | How confident the model is in its lane assignment |
recovery_probability | number (0–1) | Probability of successfully recovering the billed amount via this lane |
enforceInvariants() runs synchronously and may override the lane to human_review. The model’s original lane and the override reasons are both preserved in the DenialTriage result so the billing team can see exactly what happened.
Code-enforced invariants can override the model’s lane decision after triage. These rules protect billing teams from incorrect automation and are covered by regression tests. See Safety Invariants for details.