0K PUBLIC RELEASE // 0K-2044-0319-GLASS TITLE: #OPGLASSLEDGER // SOLVITAS CASE FILE INDEX PUBLICATION: 2044-03-19 CLASS: CLAIM / HEALTHCARE / AUTOMATED ADJUDICATION RELAY STATUS: VERIFIED ENVELOPE // 4 OF 5 PUBLIC INDEX COUNT: 1,204,611 CASE RECORDS PATIENT NAMES: REMOVED FULL MEDICAL CHARTS: NOT RELEASED DIRECT IDENTIFIERS: REMOVED WHAT REMAINS IS THE DECISION PATH. ----------------------------------------------------------------------- SAMPLE CASE INDEX ----------------------------------------------------------------------- CASE ID HOSPITAL PLAN CLASS INITIAL DECISION APPEAL DECISION -------------- ------------- ----------- ----------------- ----------------- GL-0000041182 HOSP-[RDCT] HMO-4 REJECT / AI REJECT / AI GL-0000129774 HOSP-[RDCT] PPO-7 REJECT / AI REJECT / AI GL-0000384410 HOSP-[RDCT] HMO-2 REJECT / AI REJECT / AI GL-0000782219 HOSP-[RDCT] EMP-11 REJECT / AI REJECT / AI GL-0001442098 HOSP-[RDCT] PPO-3 REJECT / AI REJECT / AI GL-0002017714 HOSP-[RDCT] HMO-9 REJECT / AI REJECT / AI GL-0005559011 HOSP-[RDCT] GOV-2 REJECT / AI REJECT / AI GL-0009981140 HOSP-[RDCT] HMO-1 REJECT / AI REJECT / AI GL-0011027718 HOSP-[RDCT] PPO-8 REJECT / AI REJECT / AI GL-0012045776 HOSP-[RDCT] GOV-4 REJECT / AI REJECT / AI ----------------------------------------------------------------------- ROUTING EXAMPLE // GL-0005559011 ----------------------------------------------------------------------- 2027-??-?? [REDACTED HISTORIC DOB] 2044-02-11 09:14:07 CLAIM RECEIVED 2044-02-11 09:14:07 MODEL: SVA-UTIL-44.2 2044-02-11 09:14:08 UTILIZATION SCORE: 0.281 2044-02-11 09:14:08 POLICY THRESHOLD: 0.300 2044-02-11 09:14:08 DISPOSITION: AUTO-REJECT 2044-02-11 09:14:09 RATIONALE GENERATED: "INSUFFICIENT CLINICAL NECESSITY" 2044-02-11 09:14:09 LETTER QUEUED TO HOSPITAL 2044-02-12 13:02:44 APPEAL RECEIVED 2044-02-12 13:02:44 APPEAL ROUTE: "INDEPENDENT REVIEW" 2044-02-12 13:02:45 REVIEW ENGINE: SVA-APX-12.8 2044-02-12 13:02:46 SOURCE MODEL SHARED FEATURE STORE: TRUE 2044-02-12 13:02:46 HUMAN REVIEW REQUESTED: FALSE 2044-02-12 13:02:46 APPEAL DISPOSITION: DENIED 2044-02-12 13:02:47 RATIONALE GENERATED: "PRIOR DECISION SUPPORTED" ELAPSED APPEAL TIME: 3.1 SECONDS ----------------------------------------------------------------------- CONTRACT EXCERPT // HOSPITAL SERVICES SCHEDULE 14-B ----------------------------------------------------------------------- "Member and provider appeals will be reviewed through an independent, second-level adjudication pathway. The second-level pathway is logically separated from the initial utilization determination service." TECHNICAL APPENDIX FIELD: SECOND_LEVEL_PROVIDER = SOLVITAS APPEAL EXPERIENCE (SAX) EXECUTION_MODE = AUTONOMOUS SHARED_EMBEDDING_STORE = ENABLED ----------------------------------------------------------------------- AGGREGATE COUNTS // PUBLIC INDEX ----------------------------------------------------------------------- INITIAL AUTO-REJECT ................................. 1,204,611 APPEALS LOGGED ........................................ 448,102 APPEALS ROUTED TO AUTOMATED SECOND LEVEL .............. 443,890 APPEALS WITH RECORDED HUMAN TOUCH ....................... 4,212 APPEALS REVERSED ........................................ 37,880 MEDIAN MACHINE APPEAL DURATION ........................ 4.8 sec MEDIAN HUMAN-TOUCH APPEAL DURATION .................. 19.4 hrs 0K NOTE: "There was an appeal" is technically true. So is "the appeal was another machine." ----------------------------------------------------------------------- PUBLIC PACKAGE STRUCTURE ----------------------------------------------------------------------- /INDEX/ 1,204,611 redacted decision rows /ROUTING/ machine path summaries /CONTRACTS/ selected service schedules and amendments /SCHEMAS/ field dictionaries /APPEAL-PATHS/ topology diagrams and execution labels /WITHHELD/ privacy log only; contents not mirrored NO PATIENT CHARTS ARE INCLUDED IN THIS PUBLIC RELEASE. END PUBLIC EXTRACT