Maksim Topchilo

policy 001-169-215235/26 · expat EXP-003739 · Tbilisi, Georgia

Approvedstep 6 of 9

Result Next step

Adequacy

step 6 of 9 · medical_adequacy · 0:49 · adequacy 82 / 100 · routing_hint continue

Approved

Runs only when the claim has medical items — whether the treatment was justified.

Verdict

82adequateconfidence 0.78

Workup and treatment match the recorded diagnosis; nothing ordered outside the indication.

Provider penalty

not applied — No cheaper in-network provider was suggested to the insured before treatment, so no penalty is available.

Step 5 context

91% over · score 91 level high

Findings

ADEQUACY_OKgreen

Cardiology consultation, echocardiography, Holter/ECG and the related panels are clinically plausible for documented tachycardia, palpitations and weakness.

NO_DUPLICATE_SERVICESgreen

No billed service appears twice across the two visits, and nothing was billed that the report does not describe.

HIGH_COST_CONTEXTorange

Step 5 reports high overpricing on the same episode. That is a price signal about this clinic's tariff and does not by itself make the services medically inadequate.

→ Open step 5

Two steps, one claim, opposite verdicts

Step 5 · Price

BLOCK — 91% above estimate

overpricing score 91, level high, action fraud_queue

Step 6 · Treatment

OK — adequate, score 82

confidence 0.78; step 6 records step 5's 91% itself and does not act on it

Both are right. The set of procedures is appropriate; what this particular clinic charges for that set is not. Presenting them side by side is what lets an operator resolve it in seconds instead of reading two step outputs and reconciling them mentally.

Step 6 decided

Approved

Adequacy

ADEQUACY_OK — workup matches the recorded diagnosis

Provider penalty

none applied