AITP Adjudication Demo

Workspace

AI Third Party Adjudication - Concept Demo

Prescription Worklist

Inbound adjudication queue

3 inbound files

Case	Patient	Drug	Run State
paid pass-through	Jane Mercer	Rosuvastatin 20 mg tablet	idle
reject, auto-fix, resubmit	Maria Jensen	Rosuvastatin 20 mg tablet	idle
paid but flagged for contract review	Daniel Ruiz	Ozempic 1 mg dose pen	idle

Waiting to runSelect an inbound JSON claim and run it through the workflow.

Workflow Progress

Selected claim progression

idle

Receive PMS JSONWaiting

Normalize pricing fieldsWaiting

Resolve contract pricing schemeWaiting

Run pre-adjudication modulesWaiting

Build telecom requestWaiting

Send to payerWaiting

Receive telecom responseWaiting

Run post-adjudication modulesWaiting

Return PMS outbound resultWaiting

Stage 1

Pre-Adjudication Modules

before telecom submit

Prepare the inbound claim, normalize pricing inputs, and resolve the approved contract pricing scheme before the telecom message is built.

PMS Inbound

Expected JSON received from the pharmacy management system

{
  "requestId": "pms-req-1001",
  "claimType": "billing",
  "patient": {
    "firstName": "Jane",
    "lastName": "Mercer",
    "dob": "1980-05-12"
  },
  "payer": {
    "bin": "012345",
    "pcn": "RXPROC1",
    "plan": "Commercial Plus"
  },
  "prescription": {
    "rxNumber": "7001458",
    "ndc": "00093015005",
    "quantity": 30,
    "daysSupply": 30,
    "dawCode": "0"
  },
  "pricing": {
    "ingredientCostSubmitted": 125,
    "dispensingFeeSubmitted": 10,
    "usualAndCustomaryCharge": 148,
    "grossAmountDue": 135
  }
}

Pricing Inputs

Drug pricing options available before telecom construction

DrugRosuvastatin 20 mg tablet

Contract SchemeNorthRiver Retail 2026 Q2

Pricing Option	Source	Amount	Status	Note
Ingredient cost submitted	PMS inbound pricing	$125.00	selected	Used as the base ingredient value under the approved contract scheme.
Dispensing fee submitted	PMS inbound pricing	$10.00	selected	Accepted directly from inbound pricing data.
Usual and customary	PMS inbound pricing	$148.00	available	Available for comparison and telecom population when required.
Gross amount due	Canonical pricing model	$135.00	selected	Final amount inserted into the telecom PRC segment.

Applied rule set	northriver-commercial-plus-retail-v3
Expected pricing basis	Submitted ingredient cost plus standard dispensing fee
Approval status	approved

Pricing Field Mapping

Inbound pricing values normalized into the canonical pricing model

Profilestandard-retail-v1

Statusmapped

ingredientCostSubmitted	125
dispensingFeeSubmitted	10
usualAndCustomaryCharge	148
grossAmountDue	135

Inbound Field	Canonical Field	Role	Transform	Result
pricing.ingredientCostSubmitted	pricing.ingredientCostSubmitted	required	direct passthrough	125.00
pricing.dispensingFeeSubmitted	pricing.dispensingFeeSubmitted	required	direct passthrough	10.00
pricing.usualAndCustomaryCharge	pricing.usualAndCustomaryCharge	optional	direct passthrough	148.00
pricing.grossAmountDue	pricing.grossAmountDue	required	direct passthrough	135.00

Contract Pricing Scheme

Admin-loaded contract guidance interpreted by AI and applied as deterministic pricing rules

Contract SetNorthRiver Retail 2026 Q2

Approvalapproved

Effective date	2026-04-01
Applied rule set	northriver-commercial-plus-retail-v3
Expected pricing basis	Submitted ingredient cost plus standard dispensing fee
AI suggested scheme	Use submitted ingredient cost and dispensing fee when values are present and aligned to NorthRiver Commercial Plus retail terms.

AI interpretation was approved and converted into deterministic pricing configuration.

No customer-specific remapping was required for this claim.

Stage 2

Adjudication

telecom exchange

Build the telecom request, submit it to the payer, and capture the returned adjudication response.

Telecom Request

Claim record sent to the payer transport boundary

[
  {
    "segment": "HDR",
    "BIN": "012345",
    "VER": "D0",
    "TX": "B1",
    "PCN": "RXPROC1",
    "COUNT": "1",
    "DOS": "20260413"
  },
  {
    "segment": "INS",
    "CARDHOLDER": "CARD100200300",
    "GROUP": "COMMERCIAL01",
    "PERSON": "01"
  },
  {
    "segment": "PAT",
    "NAME": "JANE MERCER",
    "DOB": "19800512"
  },
  {
    "segment": "CLM",
    "RX": "7001458",
    "QUAL": "1",
    "NDC": "00093015005",
    "QTY": "30",
    "FILL": "0",
    "DS": "30",
    "DAW": "0"
  },
  {
    "segment": "PRC",
    "ING": "125.00",
    "FEE": "10.00",
    "U&C": "148.00",
    "GROSS": "135.00"
  }
]

Telecom Response

Adjudication returned by the payer transport boundary

[
  {
    "segment": "RSPHDR",
    "VER": "D0",
    "TX": "B1",
    "COUNT": "1",
    "HDR": "A",
    "DOS": "20260413"
  },
  {
    "segment": "RSPSTS",
    "TXRESP": "P",
    "AUTH": "A765432109",
    "MSG": "CLAIM PAID"
  },
  {
    "segment": "RSPCLM",
    "RX": "7001458",
    "QUAL": "1"
  },
  {
    "segment": "RSPPRC",
    "PATPAY": "25.00",
    "INGPAID": "100.00",
    "FEEPAID": "10.00",
    "TOTAL": "110.00"
  }
]

Stage 3

Post-Adjudication

clear

Review the returned outcome, calculate pricing disposition, and route flagged or exception claims into the appropriate follow-up path.

Final Pricing

Pricing disposition, flags, and suggested follow-up after adjudication

Expected$110.00

Payer Result$110.00

Variance$0.00

Disposition	Paid as expected
Primary action	Release paid response to PMS and continue fill workflow
Queue reason	No queue action required.

Release paid result to PMS.

Retain pricing provenance for audit only.

PMS Outbound

Returned JSON for paid, rejected, flagged, or queued outcomes

{
  "responseId": "pms-resp-1001",
  "adjudicationStatus": "paid",
  "adjudication": {
    "headerStatus": "A",
    "transactionStatus": "P",
    "authorizationNumber": "A765432109"
  },
  "payment": {
    "patientPayAmount": 25,
    "ingredientCostPaid": 100,
    "dispensingFeePaid": 10,
    "totalAmountPaid": 110
  },
  "reviewFlags": []
}

Result Indicators

Workflow disposition

clear

Claim outcomepaid

Disposition pathauto

Queue requiredno

Header response status	A
Transaction response status	P
Authorization number	A765432109
Patient pay	$25.00
Total amount paid	$110.00

Error And Review Queue

Claims requiring human follow-up

2 queued

Patient	Drug	Queue	Owner	Next
Maria Jensen	Rosuvastatin 20 mg tablet	error queue	adjudication automation	Await retry result; escalate to manual review if still rejected.
Daniel Ruiz	Ozempic 1 mg dose pen	future review	contract review queue	Batch review with other flagged paid claims.