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Chargeback Claims Review

Chargeback validation where agents read every claim packet, fixed rules decide, and a person approves every payment

Every chargeback claim read first by agents, each verdict with its rule and evidence.

Watch the filmBook a demo
See one case, screen by screen ↓
demo2,480claims this cycle read first by agents — 100% of packets, before anyone opens one
demo2.6minmedian from packet to a verdict with its rule and evidence
proven7fixed rules run on every claim — the issue patterns found in 62,000 past claims
demo94%of holds upheld by reviewers so far this cycle — 31 of 33
The problem

Why chargeback claims are paid on a quick read

A distributor sells to a hospital at the group purchasing contract price, then claims back the difference from the list price. Every month thousands of claims arrive by EDI, by email and through the portal, with tens of thousands of supporting documents — claim forms, invoices, purchase orders, delivery notes, price lists — and the reply is due within the month.

Read by hand, a claim gets the checks there is time for: is the price on the contract, is the hospital on the roster. The harder questions go unasked — has this invoice line been claimed before by another distributor, has this purchase order already been claimed past what was ordered, was this PDF edited after the billing system printed it. And nothing from this month’s checks is kept for next month’s.

proven7distinct issue patterns found in a prior analysis of 62,000 claims
demo$412,860held in one cycle across 64 exceptions, until a person decides
demo1.2millionpast claim lines a duplicate check has to search, across every distributor
Where a monthly claim cycle’s days goestimated
By hand21 days
With the solution3.7 days
  • Sorting packets into their documents3 → 0.2 d
  • Keying claim lines and matching them to invoices6 → 0.5 d
  • Checking prices, rosters and contract terms4 → 0.3 d
  • Searching past claims and purchase orders3 → 0.2 d
  • Deciding exceptions and replying to distributors3 → 2 d
  • Writing the monthly report2 → 0.5 d

Estimated split for one cycle of about 2,500 claims, by hand and with the solution, in working days for the chargeback team.

How it works

How a claim moves

Five agents sort, read, check and rule on every claim packet; a reviewer approves every payment.

What comes in
Packets in3 channels · claim, invoices, contracts
Agents at work
Intake agentsorts the files
Then
Extraction agentlines + citations
Then
Validation agent
History agent
Then
Rules agent7 rules + score
A person decides
Chargeback reviewerapproves payment
What comes out
Verdict + evidence
Credit or reply
History kept
One case, step by step

One claim packet, from received to replied

Meridale Medical Supply sends claim CB-88213: nine files, six lines, $70,070.00 claimed for September sales. Here is what happens next, screen by screen, in the working solution.

  1. 01Morning

    The cycle, already read

    Dana Okafor · Chargeback reviewer

    Dana opens the solution on the October cycle: 2,480 claims from 6 distributors, every one read first by the agents. 64 are exceptions, $412,860 is held until a person decides, and 18 claims worth $286,430 passed all 7 rules and are ready to approve.

    Agents at work: “Intake agent · EDI feed checked 4 min ago · 12 packets overnight.”

  2. 02The queue

    Every claim, with its verdict and its reason

    Dana Okafor · Chargeback reviewer

    Each claim shows its packet, the amount claimed and held, the verdict and score, the issue found, its stage and its reply-due date. CB-88213 from Meridale sits at the top: Hold · 92, high band, for two issues — Within ordered quantity and Document unaltered — with $43,800.00 held and 29 days left to reply.

  3. 03Received 07:42

    Nine files read, sorted and checked

    The agents

    The intake agent sorts the packet into a claim form, six invoices, a purchase order and a delivery note. The extraction agent reads every line, each value cited to its page. The validation agent checks the documents against each other, the history agent searches 1.2 million past claim lines, and the rules agent runs the 7 rules.

    Validation agent: “Invoice 554812: “120” placed over “20”, edited Sep 30 · subtotal equals 20 units.”

  4. 042.6 minutes later

    Hold, score 92 — with the rule and the evidence

    Rules agent

    Two of the seven rules failed on line 1, invoice MMS-INV-554812 for 120 Corventa drug-coated balloon catheters. $43,800.00 is held; the five clean lines, worth $26,270.00, can be paid. The five rules that passed are listed too, each with a link to its source.

    Passed rule 4: “No line claimed before — 1.2 million past lines searched.”

  5. 05Rule 5

    Claimed past the purchase order

    History agent

    Purchase order SAMC-PO-77120 covers 400 balloons for July to December. Three earlier claims already used 360. This claim adds 120, making 480 — 80 over the order. The delivery note shows only 20 received. Side by side, the invoice sits next to the claim history.

    “The invoice claims 120 units; after three earlier claims the purchase order has only 40 left.”

  6. 06Rule 7

    An invoice edited after it was printed

    Validation agent

    The invoice file was edited on Sep 30 at 16:47 in a desktop PDF editor, 28 days after the billing system created it. The quantity “120” and its amount are text boxes placed over the original “20”, and the subtotal still equals 20 units: $21,700.00.

    “Left: the invoice as received. Right: the text underneath — the billing system printed 20.”

  7. 07History

    What has been claimed against this order so far

    Dana Okafor · Chargeback reviewer

    The History tab shows the purchase order claim by claim: July 140, August 160, September 60, each paid on its credit memo — and this claim’s 120 in red, past the 400 ordered. Meridale has 14 exceptions this cycle, 5 of them over a purchase order; last cycle it had 9.

  8. 08Decided

    Reject the held line, with the reason codes

    Dana Okafor · Chargeback reviewer

    The agents suggest rejecting line 1 with reasons Q-05 and A-07 and paying the five clean lines; the decision is Dana’s. The two reasons are already ticked, the held line only ($43,800.00) is chosen over the whole claim ($70,070.00), and the note to Meridale asks for the invoice from its billing system.

    E-signature: “Chargeback reviewer · meaning: rejected after reviewing the evidence.”

  9. 09Signed

    Line rejected, clean lines credited, reply sent

    Dana Okafor · Chargeback reviewer

    Line 1 is rejected with Q-05 and A-07 and e-signed by Dana. The five clean lines are approved for credit — $26,270.00 — and the response file goes back to Meridale with each line’s outcome and reason code. The claim moves to Closed, and every agent step and her decision are on its activity trail.

  10. 10Every cycle

    One integrity report, signed

    Omar Haddad · Controller

    The reporting agent drafts the cycle’s integrity report as claims are decided. September’s: 2,512 packets read, 71 claims held (2.8%) worth $468,120, 67 holds upheld, 4 paid after a corrected invoice — the patterns found, the distributors to talk to, and the rule changes made. Omar signs it.

    E-signature: “Omar Haddad · Controller · meaning: reviewed and approved · Oct 3, 2026.”

Who it’s for

Built for everyone who touches a chargeback.

The same claim cycle, seen by the four people who carry it — what their month looked like, and what it looks like now.

DO
Dana OkaforChargeback reviewer
Chargeback reviewer
Before
Reads packets by hand to find the few claims in a month that are wrong.
Now
Starts the day with 64 exceptions out of 2,480 claims, each with its rule, its evidence and a suggested decision.
SP
Sam PatelChargeback reviewer
Chargeback reviewer
Before
Checks lines against price lists one at a time; a line claimed twice, or in boxes instead of each, is easy to miss.
Now
Approves clean claims in a daily batch with one e-signature, and rejects a line with a reason code the distributor receives in its response file.
OH
Omar HaddadController
Controller
Before
Has nothing from last month’s checks to build this month’s on.
Now
Signs one integrity report a cycle — what was claimed, what was held and why — and gives the second approval whenever someone wants to pay against a failed rule.
LO
Lena OrtizContracts manager
Contracts manager
Before
Keeps the contracts, price lists and rosters every claim depends on, checked against claims only when someone has time.
Now
Her price lists, rosters and contract terms are checked against every claim line on its invoice date, and she can be named second approver for overrides.
Built on the engine

5 agents. Each with one job, and hard limits.

Five agents sort, read, check and rule on every claim packet; a reviewer approves every payment.

Intake agent

Picks up packets from the EDI feed, the claims mailbox and the portal, and splits each one into claim form, invoices, purchase orders, delivery notes and price lists.

  • Keeps the original file untouched
  • Flags packets with missing invoices
Extraction agent

Reads every claim line and its supporting documents — invoice number, date, customer HIN, item, quantity, unit, contract and prices — each value cited to its page.

  • Every value carries a citation
  • Low-confidence fields go to a person
Validation agent

Checks the documents against each other and against the contract: prices, tiers, rosters, units, and whether a file was edited after it was created.

  • Reports evidence only — never a verdict
History agent

Searches the permanent claim history: was this invoice line claimed before, and how much has been claimed against this purchase order so far?

  • Reads history only
  • Writes nothing back until a person decides
Rules agent

Runs the seven fixed rules over the evidence and returns a verdict — Pass, Partial or Hold — with the rule, the evidence and a score band. The same evidence always gives the same verdict.

  • Deterministic — no model call decides a verdict
  • Payment-affecting verdicts wait for a person
Chargeback reviewer

Approves every payment. The agents propose; a named person decides.

Ask in plain words

Ask it anything, in plain words

Reviewers can ask about any claim, rule or distributor — or tell it what to change. Every answer points to its source.

Why is CB-88213 on hold?

Two of the seven rules failed on line 1, invoice MMS-INV-554812 for 120 Corventa drug-coated balloons. Rule 5: purchase order SAMC-PO-77120 covers 400 units and 360 were already claimed July–September, so 120 more makes 480; the delivery note shows 20 received. Rule 7: the file was edited on Sep 30, 28 days after it was created, and “120” sits on top of the original “20”. $43,800.00 is held; 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; 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.

Which distributors had the most exceptions this cycle?

Meridale 14, mostly over a purchase order; Crestline 13, mostly claimed before; Northpoint 12, mostly not on the roster; Bayfield 9; Harrow & Lane 8; Summit Ridge 8. One of Crestline’s duplicates, invoice CHD-119004, was already paid on CM-41377 on Sep 24 and claimed again on Oct 6. That is worth a call.

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 recorded in the audit trail.

Every screen

The working solution, as it ships.

13 screens from the working solution, on its sample data. Pick one to see it large.

HomeThe cycle at a glance: claims read, exceptions to review, the amount held, claims ready to approve — and what the agents are doing now.
Every claimEach claim with its packet, amount claimed and held, verdict and score, issue found, stage and reply-due date, filterable by distributor and issue.
Agents at workEach step runs in view: the packet opened, the files sorted, every line read, the documents checked, the history searched, the rules run.
The verdictHold, score 92: two rules failed on one line, with the evidence for each, the amount held and the clean lines that can be paid.
Side by side: over the orderThe invoice next to the claim history — 360 of 400 already claimed on the purchase order, 120 more claimed now.
Side by side: an edited invoiceThe invoice as received next to the text underneath — the billing system printed 20, and the file was edited 28 days later.
Claim historyEverything claimed against the purchase order so far, claim by claim and credit memo by credit memo, and the distributor’s year.
Reject with reasonsReason codes, the held line or the whole claim, the note to the distributor and the reviewer’s e-signature.
Decided and repliedThe held line rejected, the clean lines credited, the response file sent — signed and on the record.
Rules, tested on last cycleThe seven fixed rules run again on 2,512 decided claims and compared with what reviewers decided.
The dashboardClaims read, exceptions and amount held, issue patterns, verdicts and the time each agent takes from packet to verdict.
The integrity reportOne report a cycle: what was claimed, what was held and why, which distributors to talk to — signed by the Controller.
Your approvals and holdsWho approves, who rejects, who signs an override, the hold score, the claim window and the channels packets come from.
Governance

Built for money that leaves the business: cited, ruled, signed.

Every value cites its pageEach value on a claim is cited to the page it was read from. Click any piece of evidence to see it highlighted in the invoice, purchase order, delivery note or history record.
Fixed rules decide, not a modelAgents read and cite; seven fixed rules turn that evidence into a verdict. The same packet always gets the same answer, and a failed payment-affecting rule always means Hold.
A person approves every paymentEvery payment, every batch of clean claims and every rejection is e-signed by a named reviewer, with the meaning of the signature recorded. Every rejection carries a reason code.
A second approver to pay against a rulePaying a held line overrides the verdict, so a second person must agree — the Controller by default — and the reviewer writes down why it should be paid.
History and originals cannot be changedThe claim history is permanent and cannot be edited. Original packet files are kept unchanged, with their fingerprint, so the evidence behind a verdict is always the file the distributor sent.
Rule changes are versioned and approvedEach rule has a named owner. Changes are versioned, can be tested on last cycle’s decided claims first, and need the rule owner’s approval. Every agent step and every decision is on the claim’s activity trail.
Configuration

Your contracts and approvals, not ours

Who signs, when a claim is held, how late is too late and where packets come from are all settings.

SettingDefaultChoose from
Paying a claimDana OkaforDana Okafor · Sam Patel · Omar Haddad
Rejecting a line — reason code and e-signatureAny chargeback reviewerAny chargeback reviewer · Dana Okafor · Omar Haddad
Overriding a held verdict — second approverOmar HaddadOmar Haddad · Lena Ortiz
Hold claims at or above score7050 to 90, in steps of 5
Claim window — later lines are flagged as late180 days after invoice90 · 180 · 365 days after invoice
Pay clean lines when one line is heldOnOn · Off
Where packets come fromEDI 844, claims mailbox, distributor portalEach channel on or off
Send response files after approval (EDI 849)OnOn · Off
Connections

Works with the channels and records you already run

Electronic claims (EDI 844)distributor claim files, checked every 15 minutes
Claims mailboxPDF claim packets sent by email
Distributor portalpackets uploaded by distributor staff
Contract price listsgroup contracts, tiers, terms, extensions and revisions
Membership rostershospitals by HIN and GLN, with group, tier and dates
Response files (EDI 849)each line’s outcome and reason code, back to the distributor
What it changes

The difference, in numbers.

Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.

target
2,500
claims a month read first by agents
of packets read before anyone opens one
proven
7
issue patterns checked on every claim
7 fixed rules
from 62,000 past claims
target
2.6min
median from packet to a verdict with rule and evidence

“demo” = seen in the working solution, on its sample claim cycle · “proven” = a prior analysis of 62,000 claims, which found issues across seven distinct patterns · “estimated” = our estimate. People, distributors, hospitals and products named on this page are characters in the working solution.

Questions

What chargeback teams ask us.

What is chargeback claims review?

Distributors sell to hospitals at the group contract price and claim back the difference from the list price. Chargeback claims review checks each claim against its invoices, purchase orders, delivery notes, contracts and rosters before the credit is paid. Chargeback Claims Review has agents read every packet first, fixed rules decide the verdict, and a reviewer approves every payment.

How does it decide whether a claim is valid?

Seven fixed rules run on every claim: contract price, customer eligible, contract in force, not claimed before, within ordered quantity, unit of measure and document unaltered. A failed payment-affecting rule gives Hold, a price difference only gives Partial, and all passed gives Pass. A score from 0 to 100 says how strong the evidence is.

Does the AI decide whether a claim is paid?

No. The agents read and cite the evidence, and no model call decides a verdict — the rules do. A person approves every payment with an e-signature, and paying against a failed rule needs a second approver.

Will it catch a duplicate chargeback from another distributor?

Yes. Rule 4 checks every invoice line — invoice number, item and quantity — against the permanent claim history, kept since 2021, from every distributor. In the working solution that is 1,214,380 lines, and a match shows the earlier claim and the credit memo it was paid on.

How does it spot an altered invoice?

Rule 7 reads the file properties, the text layers and the invoice arithmetic: whether a file was edited after it was created, whether text was placed over numbers, and whether the totals agree with the lines. It reports what it found, not intent; a person decides.

Can we pay the clean lines and hold only the problem line?

Yes. With “Pay clean lines when one line is held” on, the rest of the claim is paid and only the held line waits. The distributor gets a response file with each line’s outcome and reason code.

Can we change the rules or add our own?

Yes. Each rule has an owner; changes are versioned and need that owner’s approval. You can describe a new check in plain words — for example, lines claimed more than 180 days after the invoice — and it is drafted, tested on last cycle and held for approval before it is used.

How long does it take to go live?

The Agentic Solution Engine builds and deploys it from your requirements — your contracts, price lists, rosters, reason codes 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.

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your claim packets.

We’ll run Chargeback Claims Review on a sample of your own past claim cycles.

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