Classify each case against CMS criteria, start the right clock, assemble the evidence a reviewer needs, and draft the resolution and its notice — a qualified reviewer decides, a clinician decides anything clinical.
A case arrives — a grievance, a determination or an appeal — from the channel it was filed in.
02
Normalise the filer, the date received, the issue raised and the intake channel across sources.
Reason
03
Propose the classification against the intake criteria, and screen for language that makes it expedited.
04
Apply the plan's configured deadlines, notice rules and the state clinician-review trigger as written.
05
Bind the clock start, the classification and every deadline to the case record, and mark what intake leaves ambiguous.
Decide
06
Flag a grievance that reads like it contains an appeal, and a standard request that reads like it should be expedited.
07
Route every classification, every clock and every drafted resolution to the assigned reviewer for a decision.
Out
08
Retain the intake record, the classification rationale, the evidence and the reviewer's decision.
09
Execute write actions only inside the approval boundaries agreed during implementation.
→Product statement
The agent proposes the classification and drafts the resolution; a qualified reviewer decides, a clinician decides anything clinical, and a missed deadline still forwards to the independent review entity automatically.
2Clock and classification assembledFiler, issue raised, classification criteria, deadline rules and expedited-screening criteria
3Resolution draftedDraft resolution, notice language, cited criteria and confidence
4Controls appliedClassification checks, clock-start checks, notice-content checks and confidence threshold
No human action required
Stages 1 to 4 run unaided, and no case is closed at any of them — the agent is classifying and drafting, and the reviewer's lane opens at the confidence gate.
5DecisionBranches at the confidence threshold
High confidence
Goes to the assigned reviewer to decide.
Low confidence
Adds a compliance-officer read first.
Reviewer decision
The case is held with its classification, the evidence assembled and the confidence.
Confirm · Reclassify · Escalate
Confirmed — resolution released▼
6Case-management system updatedOnly where write access and approval policy allow it
7Outcome evaluatedClassification accuracy, clock adherence, reviewer edits and IRE-referral outcomes
Reviewer edits
Every reviewer edit made at decision is counted in the evaluation.
What should not run autonomously
Human approval stays in control
Outside the boundary — human approval required8 items
Issuing, denying or closing a determination.
Deciding anything clinical.
Making the adverse-determination call reserved for a licensed clinician.
Overriding a classification once a reviewer has confirmed it.
Automation boundaryAgent acts unaided
✓Classify the case against CMS-defined criteria.
✓Start and track the clock from the date the case was received.
✓Assemble the evidence record — the file, the criteria.
✓Draft the resolution and its notice, and hold both for the reviewer's decision.
Any write happens inside the boundaries agreed at implementation, never ahead of the reviewer's decision.
Treating a missed deadline as a delay rather than an outcome.
Assuming one national rule where the clinician-review trigger varies by state.
Merging a grievance and an appeal into a single workflow.
Changes to classification criteria or clock configuration.
Example output
One case, annotated
Everything the agent drafts is attached to the case it was drawn from.
Case output · single caseIllustrative example
Case
Drafted resolution
Case type
Filing channel
Confidence
Reviewer status
Part B drug reconsideration
Draft resolution: partial reversal — reverses the Part B drug denial on the submitted clinical evidence
24-hr expedited
Filed by the treating provider
89%
Licensed clinician review confirmed
As receivedTaken from the case file and the evidence submitted — nothing on this side is decided by the agent.
Evidence assembledProvider clinical letterDenial notice and criteriaReceipt date, clock start
Why this reads as reversibleThe submitted evidence meets the criterion the original denial cited.
ActionConfirmReclassifyEscalate
What the score decidesBelow the configured threshold the case picks up a compliance-officer read before.
Value
Where AI adds value
The same four claims, placed at the point in the workflow where each one applies.
Where the value landsValue 01 – 04
Every case filedFrom the intake channel
03Classification
Classify against criteria
Weigh the language filed against CMS's criteria for grievance, organization determination and appeal.
01Approved path
The clock is the determination
The word a filer used doesn't set the clock — the classification against CMS's criteria does.
02Human review
Point the reviewer at what needs
Cases near the expedited boundary and low-confidence classifications are marked, so the reviewer's read starts where the clock is tightest.
04Build an evidence trail
The case, the clock it was filed against and the reviewer who decided stay on the file.
Integrations
Typical integrations
Five system groups connect to the same agent. Which of them are in scope is decided in discovery.
A blended turnaround hides the case that missed it
A blended turnaround time can look compliant while a handful of case types absorb nearly all of the misses. Nestack reports the rate by case type, not only in total.
Slice performance — reported separately, not only in aggregateIllustrative example
Slice
Failure rate
Lift
Lift vs. threshold
Status
Cases arriving mid-clock from another channel
7.5%
3.9×
Review
Expedited requests filed as standard
5.6%
2.9×
Review
Grievances containing an appeal
3.6%
1.9×
Watch
Standard post-service appeals
1.9%
0.8×
Normal
Bar: misclassification rate lift vs. the standard post-service baseline · scale 0–4.0× · tick at 2.0×2 of 4 slices over threshold
Evidence-linked improvement
The loop closes on the case, not the count
A cycle ends when the misclassified case is one the next release has to catch. That suite is what the next case opened is measured against.
Improvement cycle · five stagesSwitchback — the path turns at Improve and returns at Learn
01Detect
Misclassification rate rises in a case-type slice.
02Diagnose
The case that aged into a determination is traced to the classification, the clock start or the queue behind it.
03Improve
Version-stamp the correction and attach the cases that exposed it.
04Verify
The affected cases run again, and a fail stops the release.
05Learn
It becomes a permanent test, and the classification rules move with it.
Learn → DetectThe return edge. The next case classified runs against a suite one case longer.
Typical build scope
Twelve workstreams across six weeks
The build scope read against the delivery timeline. Week structure follows the six-week plan — discovery, sources, case workflow, evaluation, integration, then production validation and handover.
WorkstreamWeek 1Week 2Week 3Week 4Week 5Week 6
01Case-workflow discovery and boundary definition.
02Case-system and channel assessment.
03Classification and clock-rule mapping and rule mapping.
04Case ingestion and normalisation.
05Classification and clock-start logic.
06Confidence scoring and flag routing.
07Reviewer decision workflow.
08Case and correspondence integration.
09Classification and clock cases.
10Guardrails and review controls.
11Case-trail instrumentation.
12Deployment, documentation and Agent Care handover.
12 workstreams · 6 weeks · bar shows the weeks a workstream is active — several run in parallelFinal scope and sequence confirmed in discovery
Engagement tiers
What each tier includes
Rows are the capabilities named in each tier's scope. Higher tiers include everything below them.
Capability✓ in scope · — not at this tierPilotOne case type, one planProductionProduction case-system integrationAdvancedMultiple lines / states
Introduced at Pilot
Classification and clock recommendations✓✓✓
Reviewer decision✓✓✓
Classification-accuracy baseline✓✓✓
Introduced at Production
Reporting by case type—✓✓
Decision workflow in your systems—✓✓
Approved case write-back—✓✓
Case-system integration—✓✓
Introduced at Advanced
Multi-state clinician rules——✓
Multi-stage reviewer chains——✓
High case volume——✓
Multi-line appeals controls——✓
Build priceFrom $5,000From $8,000Custom quote
Final build priceConfirmed after discovery based on integrations, workflow complexity, transaction volume, approval controls and deployment requirements.
Separate from buildBuild pricing is separate from recurring Agent Care, which covers managed monitoring, evaluations, incidents and verified improvements after launch.
What we need from you
What you bring, and what we build with it
Each input maps to a piece of build scope and a week in the delivery timeline.
You bringWe build with it
01Your case-management system access and intake channels→Case ingestion and channel mappingWeek 1
02Representative cases across case-type cohorts→Classification baseline and clock-start logicWeek 2
03Your classification criteria and state clinician-review rules→Classification-criteria and clock-rule mappingWeek 1
04Access to relevant APIs, feeds or exports→Case-system and channel assessment, then integration setupWeek 2
05Decisions you would not want issued→Deadline cases and the evaluation suiteWeek 4
06What no case may be closed without→Confidence scoring, flag routing, guardrails and review controlsWeek 3
07Named reviewers and clinicians to decide cases→Reviewer decision workflow, then pilot and production validationWeeks 5–6
Nothing else is requiredDeployment, documentation and Agent Care handover are ours.
Delivery timeline
Four phases across six weeks
The bands follow the work as it actually falls, so week 5 holds evaluation and pilot at once.
PhaseW1W2W3W4W5W6
DiscoveryW1
BuildW2 – W3
EvaluateW4 – W5
Pilot & LaunchW5 – W6
Week focusW1Case workflow discovery, classification mapping and boundaryW2Case-system integration and the classification baselineW3Classification logic, clock rules and review controlsW4Evaluation suite, guardrails and failure-mode testingW5Correspondence integration, pilot cases and correctionsW6One case cycle worked under the appeals manager, then Agent Care handover
Reading the bandA bar covers the weeks its work is named in, and nothing else. The week 5 overlap is real, not padding.
At the end of W6Once the cycle validates, monitoring moves to Agent Care.
DurationSix-week plan shown · typical delivery 4–6 weeks depending on scope confirmed in discovery.
Next step · Healthcare AI agent
Build an appeals & grievances agent around your case clock.
Show us your case types, your clocks and who signs the notice. We'll map the classification workflow around your reviewer — and the clinician beside them who makes any clinical call.
