Screen 04[BUILT]
Prior-auth PA-8843 auto-denied despite high-risk note
Healthcare Prior-Auth · CMS medical necessity / utilization management — one entry in Company XYZ's versioned library of : preserved decision conditions paired with an Authorized Expected Behavior, reused on every future candidate version.
Company XYZ decision accountability · LoanCore Underwriting 3.2.0Healthcare Prior-Auth · PA-8843— Representative lending boundary case
- ACCOUNT1–3→
- VERIFY4–7→
- DEFEND8–9
VERIFYScreen 04
- Question
- Which decision conditions must future versions continue to handle correctly?
- Answer
- Company XYZ has preserved representative, boundary, disputed, and previously failed decisions as reusable Assurance Scenarios.
- Output
- A versioned library of decision conditions with authorized expected outcomes.
Fault attribution · Rule failure
A rigid deterministic gate denied a case the underlying model would have passed.
Decision chain
[BUILT]captured evidenceINPUT
Auth request
CPT 78452, high_risk_note=true
TOOL
Criteria bundle v2
InterQual mapping (subset)
MODEL
Necessity classifier
Score 0.42 — below threshold
RULE
Failing or uncertain nodeAuto-deny gate
score<0.5 → DENY without human review
DECISION
Denial issued
Letter sent to member and provider
Why this case is useful for release assurance
- source_decision
- PA-8843, cardiac stress imaging
- trigger
- 96 auto-determinations missing human-review evidence
- failing_node
- Auto-deny gate
- evidence_level
- E4
- replayability
- Replay-ready from the sealed cassette
- missing_evidence
- Appeal outcome not captured; the source system does not emit appeal records yet.
- applicable_policy
- Utilization Management Policy 7.1 (2026-04)
- expected_behavior
- Authorized by Clinical Compliance / UM — Dr. Elena Voss
- suggested_preservation
- Preserve decision-time policy version and human-review evidence on the next occurrence
- suggested_scenario
- Add to the Healthcare Prior-Auth Release Scenario set as a policy-derived case
Candidate provenance
- evaluator
- company-xyz-evaluator v0.6.2
- frozen_input_set
- healthcare-prior-auth-sweep-2026-07
- evaluated_at
- 2026-07-22T04:15:00Z
- source_evidence
- sha256:6b41…c02e
- relationship_confidence
- Confirmed — decision and adverse-action record share a source identifier
- known_limitations
- Does not include appeals data; advisory only.
Captured decision
PA-8843, cardiac stress imaging
Outcome
AUTO-DENIED
reason: criteria_bundle_v2 missed 'high_risk_note=true'
Authorized Expected Behavior
Route to clinician review whenever high_risk_note is set.
Evidence
E4sufficient for verification
cassette · sha256:6b41…c02e
Next action
Advisory only. An must define or approve the expected behavior before a candidate version can be verified against it.
→ Authorize expected behaviorScreen anatomy
What this screen proves
For any single decision case, Notary AI can show which nodes ran, which node is failing or uncertain, what was captured, what evidence is missing, and what the record is at.
Why it matters
This is how a case earns a place in the release-assurance suite. A useful case has preserved evidence, a known applicable policy, and a clear expected behavior worth testing every future candidate version against.
Built or Planned
Planned capability for candidate generation; the decision-chain view and evidence grading are built. Candidates shown here are a seeded illustration.
Important boundary
The candidate is advisory. Notary AI does not determine what the acceptable outcome should be — an supplies the Authorized Expected Behavior on Screen 05, and the re-checks eligibility server-side.
Related requirements
Next
A scenario preserves the conditions, but it cannot decide what outcome is acceptable. An authorized Company XYZ reviewer must establish that.
Authorized Behavior →