DEMO MODE
Risk Prioritization
Classification rules. Analyst-routed signals.
Decision support classification
Routing to Analyst Review Queue or Prepayment Escalation. Final disposition requires a human analyst.
Risk Classification Summary
Claims Classified
1,847
Past 30 days
High Priority
312
P1 classification
Medium Priority
891
P2 classification
Routed to Analyst Review
1,203
Queue handoff
Prepayment Escalation
144
Escalation candidates
Operational Rule Library Signals
| Rule | Library Severity | Firings (30d) |
|---|---|---|
| Last updated 2 min ago · Auto-refresh paused | ||
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Threshold Evaluation
Billed-Amount Threshold
$2,500
Provider Volume Threshold
180
/wkDuplicate-Window Threshold
72
hrsGeographic Context Inputs
| State | Providers in Context |
|---|---|
| Last updated 2 min ago · Auto-refresh paused | |
| Loading | |
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Provider History Inputs
Avg. Enrollment Tenure
1 yrs
Weighted across active providers
Prior-Period Rule Firings
3
Historical baseline
Repeat-Offender Cohort
2
≥3 firings, prior 90d
Routing Distribution
Return to Adjudication3
Analyst Review Queue6
Prepayment Escalation5
Prioritized Risk Signals
| Signal ID | Domain | Provider | Trigger Rule | Risk Classification | Routing Outcome | Explanation |
|---|---|---|---|---|---|---|
| Last updated 2 min ago · Auto-refresh paused | ||||||
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Top Detection Rules Active This Period
| Rule | Flag Count | Regulatory Basis | Confidence Range |
|---|---|---|---|
| Last updated 2 min ago · Auto-refresh paused | |||
| Billing Velocity Threshold (>400% baseline) | 23 flags | 42 CFR 455.23 | 91–97% |
| Provider Referral Concentration | 18 flags | CMS-2390-F | 83–90% |
| Cross-County Route Anomaly | 14 flags | 42 CFR 455.23 | 78–86% |
| Same-Day Multi-Provider Billing | 11 flags | CMS-2390-F | 72–84% |
| Pharmacy Density Outlier | 9 flags | 42 CFR 455.23 | 68–79% |
Billing Velocity Threshold (>400% baseline)
- Flag Count
- 23 flags
- Regulatory Basis
- 42 CFR 455.23
- Confidence Range
- 91–97%
Provider Referral Concentration
- Flag Count
- 18 flags
- Regulatory Basis
- CMS-2390-F
- Confidence Range
- 83–90%
Cross-County Route Anomaly
- Flag Count
- 14 flags
- Regulatory Basis
- 42 CFR 455.23
- Confidence Range
- 78–86%
Same-Day Multi-Provider Billing
- Flag Count
- 11 flags
- Regulatory Basis
- CMS-2390-F
- Confidence Range
- 72–84%
Pharmacy Density Outlier
- Flag Count
- 9 flags
- Regulatory Basis
- 42 CFR 455.23
- Confidence Range
- 68–79%