Deterministic POC demonstration using synthetic data

UC5 - Claims Ingestion and Normalization

Receive, parse, validate, normalize, then accept or investigate the exception, explain, and route. Successful claims bypass investigation.

Choose a synthetic scenario

Request payload

POST /claims/process - X12 837P

ST*837*0003~BHT*0019*00*ABC125*20260829*1202*CH~NM1*IL*1*DOE*SAM****MI*M003~NM1*82*1*JONES*AMY****XX*1098765432~CLM*C1003*220.00***11:B:1*Y*A*Y*I~HI*ABK:R079~SV1*HC:93000*220.00*UN*1***1~SE*7*0003~

Simulated downstream error: MAP-204: diagnosis pointer transformation failed for trading partner TP-17

Workflow stages

01Receive
Synthetic 837P transaction received.
02Parse
Deterministic X12 parsing.
03Validate
Required-field validation.
04Normalize
Canonical claim JSON created.
05Accepted / Investigate
Successful claims bypass investigation. Exceptions open an investigation case.
06Explain and route
Root cause, runbook evidence, and queue.

Control point. Parsing, validation, and normalization are deterministic. A successful claim does not call the investigation flow.

DOWNSTREAM_EXCEPTIONClaim CLM-003Human review false

Canonical claim

Created

{
  "memberId": "M003",
  "renderingProviderNpi": "1098765432",
  "claimNumber": "C1003",
  "totalCharge": 220,
  "diagnosisCodes": [
    "R079"
  ],
  "serviceLines": [
    {
      "procedureCode": "93000",
      "charge": 220
    }
  ]
}

Investigation

Root cause. Downstream diagnosis-pointer mapping transformation failed.

Evidence.

MAP-204: diagnosis pointer transformation failed for trading partner TP-17
Runbook: MAP-204

Recommended route. Claims Integration Support

Confidence. 0.94

Grounded in. claims_runbook.md

Approved runbook entry - MAP-204

Meaning. A downstream mapping step failed while transforming claim line diagnosis pointer information.

Evidence. Transaction id, trading partner, mapping version, diagnosis segments, service line, and transformation log.

Recommended action. Route to claims integration support. Compare the active trading-partner mapping with the canonical mapping and replay only after correction.

The investigation assistant may explain and route an exception. It must not change claim financial values, invent missing identifiers, or adjudicate payment.

Audit events

Claim received
Deterministic X12 parsing invoked
Deterministic validation completed
Canonical claim created
Downstream exception investigation invoked

Saved response - demo_outputs.json

{
  "claim_id": "CLM-003",
  "status": "DOWNSTREAM_EXCEPTION",
  "canonical_claim": {
    "memberId": "M003",
    "renderingProviderNpi": "1098765432",
    "claimNumber": "C1003",
    "totalCharge": 220,
    "diagnosisCodes": [
      "R079"
    ],
    "serviceLines": [
      {
        "procedureCode": "93000",
        "charge": 220
      }
    ]
  },
  "validation_errors": [],
  "investigation": {
    "root_cause": "Downstream diagnosis-pointer mapping transformation failed.",
    "evidence": [
      "MAP-204: diagnosis pointer transformation failed for trading partner TP-17",
      "Runbook: MAP-204"
    ],
    "recommended_route": "Claims Integration Support",
    "confidence": 0.94,
    "grounded_in": "claims_runbook.md",
    "human_review_required": false
  },
  "human_review_required": false,
  "audit": [
    "Claim received",
    "Deterministic X12 parsing invoked",
    "Deterministic validation completed",
    "Canonical claim created",
    "Downstream exception investigation invoked"
  ]
}

Implementation boundary

The current POCs use local deterministic implementations to test workflow contracts, fixed controls, task structure, tool boundaries, and exception paths.
They do not call an LLM or Amazon Bedrock.
A production architecture can introduce an approved model gateway, such as a Bedrock-based gateway, without changing task and tool contracts.
This web experience replays the exact saved outputs of the supplied POC package. It is not an LLM result, a Bedrock result, or a production result.

The POC does not validate X12 through AI, adjudicate payment, change financial values, or invent identifiers.