Self-funded employers where medical administration, pharmacy data, and specific stop-loss are split across vendors or are changing during a run-in/run-out transition.
No. It does not determine medical necessity, coding, disputed eligibility, coverage, COB/subrogation, or denials. It reconciles supported paid-claim facts to already-resolved policy predicates and reimbursement evidence.
No. If an existing administrator or advisor already performs equivalent cross-feed stop-loss reimbursement auditing, the review is likely redundant.
No. Public procurement evidence can identify a reconciliation surface, but it does not prove an incomplete handoff, missing historical data, or buyer-recognized pain. Those are discovery questions. Unknown public evidence is never scored as pain.
The Aggregating Specific Deductible is treated as a decisive Specific-layer term. The applicable member Specific deductible or laser is applied first, then the shared ASD. If more than one member can consume a positive ASD, authenticated claimant allocation or chronology evidence is required; without it, affected members hold rather than producing a positive reimbursement exception.
Unsupported governing modifiers—such as conditional deductible step-downs, Bridge/Gapless renewal, advance-funding or deemed-paid treatment, and mirroring/policy-alignment—are detected and placed on hold. V1 does not decide clinical/program applicability or silently reinterpret the paid window.
The workpaper retains supplied claim, submission, carrier acknowledgment, and payment references so an employer can see which downstream records are actually evidenced. A chain is complete only when a submission explicitly references the reconciled claim rows and the acknowledgment/payment links are evidenced. A missing claim-to-submission link or carrier acknowledgment is reported as a control gap only; it does not change a reimbursement status or establish entitlement to payment.
Carrier forms and condition sheets can add fail-closed evidence prerequisites without authorizing policy terms. Current V1 guards include Symetra separate-PBM Rx-experience receipt, Symetra final signed Plan Document acceptance, and QBE advance-reimbursement prerequisites. If applicability or required evidence is unresolved, positive reimbursement exceptions hold.
No. The authenticated policy packet controls. Endorsements and jurisdiction-specific provisions can modify a base deadline; unresolved deadline exceptions or state-law overrides are held and cannot produce a positive reimbursement exception.
Not in this public validation build. Identifiable member-level claims remain disabled until an executed BAA and an operational BAA-ready security/privacy stack exist. The policy/modifier screen occurs before member data is requested.
No. The end-to-end workpaper accepts issued policies, endorsements, or explicitly incorporated proposals as governing document roles. Request/marketing material can guide research but cannot authorize a reimbursement conclusion.
No. The basis determines ordinary incurred/paid windows. Terminal liability is a separate election. The engine derives ordinary run-out from basis without claiming a terminal-liability election; if terminal liability is actually decisive to the reviewed claim window and its election is unstated, the workpaper holds.
No. Renewal-only No New Laser language is not treated as an empty current laser schedule. A current “No Lasers” statement or the actual current laser schedule is required.
Aggregate stop loss is review-only and is not part of the deterministic V1 release claim.