Chargeback processing where agents read every claim packet, fixed rules decide, and a person approves every payment
Every chargeback claim read first, each verdict with its rule and evidence
See one case, screen by screen ↓A manufacturer sells to a distributor at WAC. The distributor sells to a hospital at the lower price its purchasing-group contract gives it, then claims the difference back as a chargeback. Most EDI 844 lines clear automatically against the contract, the roster and the price file. The rest land in an exception work list, where an analyst opens the PDF packet — claim form, invoices, purchase orders, delivery notes — looks up the contract term, the tier and the member's eligibility by hand, and answers line by line on the EDI 849 within a short window.
The leakage sits in what the EDI check cannot see. A quantity pasted over an invoice. A purchase order already used up by three earlier claims. An invoice line paid once and claimed again, by the same distributor or another. A contract price claimed two days after the term ended. Nothing is remembered from one cycle to the next, so cumulative and duplicate checks are close to impossible by hand.
Estimated split for one stopped claim packet, worked by hand and with the solution.
Five agents read and check every packet; seven fixed rules decide; a reviewer approves every payment.
Tuesday 6 October 2026, the October claim cycle for September sales at Halvern Medical, a maker of devices and disposables sold through six distributors. At 09:52 three packets arrive. Here is what happens next, screen by screen, in the working solution.
Dana's home screen is the packet line: Read by agents, Rules decide, People approve, Paid. This cycle 2,480 packets have come in; 64 are stopped at a rule with $412,860 held, 18 are ready to approve for $286,430, and 2,397 are decided. The panel on the right already shows the highest-scoring stopped packet, CB-88213 from Meridale, held at rules 5 and 7.
“Agents read and cite. They never give a verdict.”
The intake agent picks up 3 packets: Summit Ridge by EDI 844 with 9 PDFs, and Crestline through the portal with 6 files. The extraction agent reads 6 lines and 72 fields, each cited to its page. The validation agent checks invoices, contracts and rosters and notes that invoice SRD-60458 is dated Oct 2. The history agent searches 1.2 million past lines.
Median per packet: intake 6 s · extraction 1.6 min · validation 41 s · history 9 s.
Each packet passes the rules gate: seven rule lights, and no model decides. CB-88249 from Summit Ridge passes all 7 rules and moves to People approve. CB-88250 from Crestline stops at rule 4, Not claimed before: invoice line CHD-121577 was already paid on credit memo CM-42794.
Line log: “Rules agent stopped CB-88250 at rule 4 · CHD-121577 already paid on CM-42794.”
Summit Ridge Distribution claims two lines for Granite Falls Medical Center. Line 1, invoice SRD-60458, 60 boxes of hydrophilic guidewires, is priced on contract CHP-2023-0144. The agents read the invoice date (Oct 2, 2026), the contract on the claim form, the contract end (Sep 30, 2026) and the contract register (no extension), each with its source and confidence. The rule compares the dates and fails: $5,520.00 held, $1,960.00 payable, score 84.
“Oct 2, 2026 > Sep 30, 2026 — FAIL · Fixed logic · rule 3 (C-03) v1.6 · owner Omar Haddad · no model decides.”
Below the comparison sits the clause the rule enforces: Cedarline agreement CHP-2023-0144, §3.1 Term. Granite Falls signed the renewal, CHP-2025-0207, but it starts Nov 1, 2026. Line 2, invoiced Sep 28, is inside the term and passes. The suggestion: reject the held line with reason C-03 and pay the clean line.
“This Agreement begins October 1, 2023 and ends September 30, 2026, unless extended in writing under §3.2. Contract prices apply only to products invoiced during the Term (§7.4).”
The reject dialog has C-03, Contract not in force on the invoice date, already ticked among the seven reason codes. Dana rejects the held line only, $5,520.00, rather than the whole claim at $7,480.00. The note to Summit Ridge is drafted from the evidence, and her e-signature carries its meaning.
“Dana Okafor · Chargeback reviewer · meaning: rejected after reviewing the evidence.”
The line log records it: Dana Okafor rejected the CB-88252 held line, C-03, e-signed, $1,960.00 credited. The response goes to Summit Ridge and the Paid station moves to 2,398. The panel moves on to the next stopped packet, CB-88250, for her to decide.
“CB-88252: held line rejected (C-03) · response sent to Summit Ridge · $1,960.00 credited.”
Opened from the claims list, CB-88252 shows the invoice with every cited value highlighted, the claim form, delivery note, price list and claim history. On the right: line 1 rejected with C-03, one clean line approved for credit, the response file sent, Dana's e-signature, and rule 3 with its evidence, the clause and the comparison.
Meridale Medical Supply claims $70,070.00. Purchase order SAMC-PO-77120 covers 400 drug-coated balloon catheters; 360 were already claimed in July, August and September, so 120 more makes 480, 80 over. The delivery note shows 20 received. The invoice was created Sep 2 and modified Sep 30, 28 days later, with “120” placed over “20”, and the subtotal still reads $21,700.00 for 20 units. Rules 5 and 7 fail: score 92, $43,800.00 held, 5 clean lines worth $26,270.00 can be paid.
“360 + 120 = 480 > 400 ordered → fail”
Each cycle the reporting agent writes the integrity report: what was claimed, what was held and why, and which distributors to talk to. September's covers 2,512 packets and 71 claims held, worth $468,120. Reviewers upheld 67 holds; 4 were paid after the distributor sent a corrected invoice. Omar Haddad signed it on Oct 3.
“Meridale Medical Supply — 6 claims over a blanket purchase order, most of them balloon catheters.”
The same claim cycle, seen by the four people who carry it — what their month looked like, and what it looks like now.
Five agents read and check every packet; seven fixed rules decide; a reviewer approves every payment.
Picks up packets from the EDI 844 feed, the claims mailbox and the distributor portal, groups every file that belongs to one claim and sorts its pages into claim form, invoices, purchase orders, delivery notes and price lists.
Reads every claim line and its supporting documents — invoice number, date, customer HIN, item, quantity, unit, contract and prices — and cites each value to the page it came from, with a confidence.
Checks the documents against each other and against the contract: price and tier on the invoice date, roster membership, units, and whether a file was edited after it was created.
Searches the permanent claim history — 1,214,380 lines since 2021, from every distributor — for the same invoice line, and adds up every quantity claimed against the same purchase order.
Runs the seven fixed rules over the cited evidence and returns a verdict — Pass, Partial or Hold — with the rule, the evidence, the contract clause and a score. The same evidence always gives the same verdict.
Approves every payment. The agents propose; a named person decides.
Ask why a packet stopped, filter the claims, or change who approves — in plain words. Every answer cites the document it came from.
Why did CB-88252 stop at Rules?
Rule 3 compares the invoice date with the contract term. CB-88252 from Summit Ridge prices invoice SRD-60458, dated Oct 2, 2026, on contract CHP-2023-0144, which ended Sep 30, 2026 (§3.1) and was not extended. Granite Falls' renewal starts Nov 1. The agents read the two dates; the rule compared them — $5,520.00 held, the Sep 28 line can be paid.
Why is CB-88213 on hold?
Two of the seven rules failed on line 1. Rule 5: purchase order SAMC-PO-77120 covers 400 units; 360 were already claimed July–September, so 120 more makes 480, and the delivery note shows 20 received. Rule 7: the file was edited on Sep 30, 28 days after it was created; “120” sits on top of the original “20”. Score 92; $43,800.00 is held and the other 5 lines ($26,270.00) are clean.
Show me every claim with an altered document
5 claims this cycle have a supporting file edited after it was created, and the claims list is filtered to them. The highest score is CB-88213 (92). The check reads the file properties, the text layers and the invoice arithmetic — no guesswork about intent; a person decides.
Hold claims over $50,000 for a second approver
Done. Claims over $50,000 now need Omar Haddad (Controller) as second approver before payment. It applies from the next approval — 3 claims in this cycle are affected, including CB-88213 ($70,070.00). The change is under Settings → Approvals and on the audit trail.
13 screens from the working solution, on its sample data. Pick one to see it large.
Who signs what, when a claim is held and where packets come from are settings, saved and recorded in the audit trail.
| Setting | Default | Choose from |
|---|---|---|
| Paying a claim | Dana Okafor | Dana Okafor · Sam Patel · Omar Haddad |
| Rejecting a line | Any chargeback reviewer | Any chargeback reviewer · Dana Okafor · Omar Haddad |
| Overriding a held verdict | Omar Haddad | Omar Haddad · Lena Ortiz |
| Hold at score | 70 | Step up or down; the effect on this cycle is shown beside it |
| Claim window | 180 days after invoice | 90 · 180 · 365 days after invoice |
| Pay clean lines when one line is held | On | On · Off |
| Where packets come from | EDI 844 every 15 minutes, claims mailbox, distributor portal | Each source connected or off |
| Send response files after approval | On — EDI 849 with reason codes | On · Off |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample claim cycle · “estimated” = our estimate · “typical” = published figures (Drug Channels Institute, as cited by BioXconomy — about $416 billion in brand-drug gross-to-net reductions in 2025; Chronicled whitepaper, 2021 — about 4% of chargebacks in error; Pramata — resubmission windows of 30–60 days). The seven rules reflect a prior analysis of 62,000 claims. People, companies, hospitals, contracts and products named on this page are fictional — characters and sample data in the working solution.
Software that takes a distributor's chargeback claim from the EDI 844 file and its supporting documents to a decision, a credit memo and an EDI 849 response. Chargeback Processing adds agents that read the PDF packet behind each claim and cite every value to its page, seven fixed rules that decide the verdict, and a reviewer who approves every payment.
Seven rules: contract price for the customer's tier on the invoice date, customer eligible on the roster, contract in force, not claimed before, within the ordered quantity, unit of measure, and document unaltered. They match the seven patterns found in a prior analysis of 62,000 claims.
The history agent searches the permanent claim history — every line since 2021, from every distributor — for the same invoice number, item and quantity. If the line was already credited, rule 4 holds it and shows the earlier claim and its credit memo.
The validation agent reads the file properties, the text layers and the invoice arithmetic. On the sample packet CB-88213 it found the file modified 28 days after it was created, with “120” placed over “20” and a subtotal that still matched 20 units. Rule 7 holds the line; a person decides.
No. Agents read and cite; they never give a verdict. Seven fixed, versioned rules decide, and the same evidence always gives the same verdict. A person approves every payment, every rejection carries a reason code and an e-signature, and paying against a failed rule needs a second approver.
Yes. Who approves payments, rejections and overrides, the hold score, the claim window, paying clean lines when one is held, the packet sources and sending EDI 849 response files are all settings. Rule changes are tested on last cycle and wait for approval.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your distribution agreements, purchasing-group contracts, price lists, rosters and a sample of past claim packets — and it goes live once every quality gate has passed. We will walk you through it on your own claims first.
The quarterly risk narrative drafted in minutes, every figure from a live query
1-min demoSales Playbook AutomationThe right playbook for every market and product, built 70% faster.
1-min demoPromotional Claims SubstantiationEvery claim tied to the page that supports it before MLR review
1-min demoWe'll run Chargeback Processing on a sample of your own past claim packets.