R09.03.01.04 · TASK CLASS

Prior authorization, appeals & claims

Complete payer portal workflows with documents and statuses.

20 project-authored proposals · taxonomy v1.1 · 0 new benchmark runs. Verifiers and partial-credit rules below are designs, not executed results.

Typical applications: payer portals (sandbox) · HealthAdminBench-style apps
Class GUI-need label: G3 · GUI-only

Task proposals · 20

Expand to inspect the complete original wording and proposed checks. Original proposal text remains English in both interfaces.

R09.03.01.04-T01 Submit a lumbar MRI prior authorization with supporting chart evidence

Original instruction

Synthetic patient 'Alvarez, Tomas' needs an MRI lumbar spine (CPT 72148). In the sandbox EHR find the diagnosis, symptom duration, 6+ weeks of conservative therapy (PT notes, NSAID trial) and red-flag status, then submit a prior authorization in the sandbox payer portal 'Acme Health' with those answers and the 2 supporting notes attached. Record the reference number in the EHR task.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: multi · Cross-app type · Text & forms click · Point & click
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app
Proposed difficulty: 3 / 5

Proposed verifier

Portal DB submission: CPT, ICD-10, questionnaire answers exact vs chart facts; 2 attachments are the correct note PDFs (hash); EHR task contains the portal reference number. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

25% correct codes; 35% questionnaire answers; 20% attachments; 20% reference recorded in EHR

R09.03.01.04-T02 Check five pending authorizations and record their status in the EHR

Original instruction

The EHR worklist 'PA Pending' has 5 synthetic patients with authorizations submitted to sandbox portal 'Acme Health'. Look up each case in the portal and record status (approved/denied/pended), auth number and approved units/date range in each EHR authorization record.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: multi · Cross-app nav · Pan/zoom/scroll type · Text & forms
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app
Proposed difficulty: 2 / 5

Proposed verifier

EHR authorization records for the 5 cases: status, auth number, units and date ranges exact vs the portal's seeded decisions. The agent holds no payer or EHR API credentials and the VM has no shell; the EHR audit trail must show the updates came from the browser session.

Proposed partial credit

40% cases 1-2 fully recorded; 40% cases 3-4; 20% case 5 (equal share per case)

R09.03.01.04-T03 Appeal a medical-necessity denial with a drafted letter and evidence

Original instruction

Acme Health denied the PA for synthetic patient 'Brooks, Lena' (sleep study, CPT 95810) citing 'insufficient documentation of OSA symptoms'. From the EHR, gather Epworth score, BMI, witnessed apneas and comorbidities, draft an appeal letter in the portal's appeal form addressing the denial reason with citations to the attached notes, attach the evidence and submit the first-level appeal.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: multi · Cross-app type · Text & forms click · Point & click
Work product: WP01 · Document
Conditions: multiapp · Multi-app
Proposed difficulty: 4 / 5

Proposed verifier

Portal appeal record linked to the denied case; attachments include the 3 gold documents; letter content checked by rubric: 4 required clinical facts with correct values (string match) and denial reason addressed (LLM judge, stated, 25% weight). The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

15% appeal linked to case; 25% attachments; 35% clinical facts; 25% LLM-judged argument

R09.03.01.04-T04 Process a power wheelchair DME order with face-to-face documentation

Original instruction

Process the DME order for synthetic patient 'Kim, Daniel' (power wheelchair, HCPCS K0823) in the sandbox DME portal: verify the face-to-face exam note within 6 months, the mobility assessment and home assessment in the EHR, complete the CMN/order form fields, attach the required documents and submit. If a required document is missing, create an EHR task to the provider instead of submitting.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: multi · Cross-app type · Text & forms click · Point & click
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app clarify · Ask when unclear
Proposed difficulty: 4 / 5

Proposed verifier

Seeded home assessment is missing: correct outcome is no portal submission plus an EHR task naming the missing document; partially filled draft allowed. A twin fixture with complete docs requires submission with exact fields. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

30% documents checked (audit log); 40% correct submit/hold decision; 30% task or submission fields

R09.03.01.04-T05 Request a peer-to-peer review slot for a denied case

Original instruction

For the denied PA of synthetic patient 'Patel, Ravi' in sandbox portal 'Acme Health', request a peer-to-peer review with the ordering physician 'Dr. Test Grant': choose a slot within the 14-day window that fits the physician's availability in input/provider_calendar.ics, and add the confirmation to the EHR calendar.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: click · Point & click multi · Cross-app nav · Pan/zoom/scroll
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app
Proposed difficulty: 2 / 5

Proposed verifier

Portal P2P request exists for the case in a slot within the window and not overlapping the provider's busy times; EHR calendar event with the confirmation number at the same time. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

40% valid P2P slot; 30% no calendar conflict; 30% EHR event with confirmation

R09.03.01.04-T06 Determine which of eight procedures require prior authorization

Original instruction

Using the sandbox payer portal's 'PA requirement lookup' for plan 'Acme Gold PPO', check the 8 CPT/HCPCS codes in input/scheduled_procedures.csv for the given places of service and write output/pa_required.csv with yes/no and the portal's rule ID for each.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox)
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: type · Text & forms click · Point & click
Work product: WP12 · Answer/decision
Conditions: None declared
Proposed difficulty: 2 / 5

Proposed verifier

Yes/no and rule ID exact for all 8 vs seeded rules (2 codes depend on place of service). The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

80% yes/no per code; 20% rule IDs

R09.03.01.04-T07 Complete a PDF prior-auth form and send it through a sandbox fax portal

Original instruction

Payer 'Beta Care' only accepts faxed PA requests. Fill input/beta_pa_form.pdf (fillable) for synthetic patient 'Ross, Hannah' (CT abdomen with contrast) from the EHR chart, attach the clinical note, and send it via the sandbox fax portal to the number on the form with a cover sheet. Log the fax confirmation in the EHR.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: type · Text & forms multi · Cross-app click · Point & click
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app
Proposed difficulty: 3 / 5

Proposed verifier

Fax sink receives one transmission to the correct number; PDF form fields extracted and compared with chart facts (14 fields); pages include cover sheet and note; EHR log has the confirmation ID. The VM has no shell or PDF tooling and no fax or EHR API credentials are issued, so the form must be filled and faxed in the browser; the fax sink logs the originating web session.

Proposed partial credit

50% form fields; 20% attachments and cover; 15% correct destination; 15% EHR log

R09.03.01.04-T08 Submit a retroactive authorization for an emergency admission

Original instruction

Synthetic patient 'Moreno, Luis' was admitted through the ED on Saturday for sepsis. Acme Health requires notification within 2 business days. In the sandbox portal submit an inpatient admission notification/authorization with admit date/time, diagnosis codes, attending NPI and the H&P attached, then record the case number in the EHR.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: multi · Cross-app type · Text & forms click · Point & click
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app
Proposed difficulty: 3 / 5

Proposed verifier

Portal case: type inpatient-notification, admit datetime and ICD-10 codes exact, NPI exact, H&P attached; submitted within the sandbox deadline; EHR case number recorded. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

25% request type; 35% clinical fields; 20% attachment; 20% EHR record

R09.03.01.04-T09 Request a biologic with step-therapy documentation

Original instruction

Submit a pharmacy PA in the sandbox portal for adalimumab for synthetic patient 'Nash, Erin' with rheumatoid arthritis. The plan requires failure of methotrexate >=12 weeks and one other csDMARD: extract therapy names, doses, dates and reasons for discontinuation from EHR notes and the medication history, answer the step-therapy questionnaire and attach the rheumatology note and latest TB test.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: multi · Cross-app type · Text & forms nav · Pan/zoom/scroll
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app hidden · Hidden/stale state
Proposed difficulty: 4 / 5

Proposed verifier

Questionnaire answers exact: methotrexate dose and dates (>=12 weeks), second agent (leflunomide) with dates, discontinuation reasons; attachments correct (hash); diagnosis code exact. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

40% step-therapy answers; 20% diagnosis and drug details; 25% attachments; 15% submitted

R09.03.01.04-T10 Fix a rejected submission missing NPI and taxonomy

Original instruction

A PA submitted yesterday in the sandbox portal for synthetic patient 'Yu, Grace' was rejected 'Rendering provider NPI/taxonomy invalid'. Look up the rendering provider's NPI and taxonomy in the EHR provider directory, correct the submission (resubmit or edit, as the portal allows), and confirm the new status is 'In review'.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: multi · Cross-app type · Text & forms click · Point & click
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app
Proposed difficulty: 3 / 5

Proposed verifier

Portal case shows corrected NPI and taxonomy exact, status 'In review', no duplicate new case created; other fields unchanged. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

40% NPI and taxonomy; 30% status; 30% no duplicate and no collateral change

R09.03.01.04-T11 Inquire claim status and submit a corrected claim in a payer portal

Original instruction

In sandbox portal 'Acme Health', look up claim status for synthetic patient 'Diaz, Marco' DOS 2026-09-03. It was paid at the wrong units for J-code J0897. Submit a corrected claim (frequency code 7) through the portal's claim correction form with the right units from the EHR medication administration record.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: multi · Cross-app type · Text & forms click · Point & click
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app
Proposed difficulty: 3 / 5

Proposed verifier

Portal correction record: references original claim number, frequency 7, J0897 units equal the MAR-derived value, other lines unchanged. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

20% status checked; 30% original claim referenced; 40% corrected units; 10% no other changes

R09.03.01.04-T12 File a second-level appeal and an external review request

Original instruction

Synthetic patient 'Fischer, Anna' had a first-level appeal upheld for proton therapy. In the sandbox portal file a second-level appeal within the deadline with the new comparative dosimetry plan and medical literature attached, and also complete the state external review request form (PDF, sandbox regulator portal) with the case details.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: multi · Cross-app type · Text & forms click · Point & click
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app long · Long-horizon
Proposed difficulty: 5 / 5

Proposed verifier

Second-level appeal linked to the first-level case, before deadline, with 2 required attachments; external review form submitted in regulator sandbox with 12 fields exact; EHR log updated with both reference numbers. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

35% second-level appeal; 35% external review form fields; 15% attachments; 15% EHR log

R09.03.01.04-T13 Request additional physical therapy visits on an existing authorization

Original instruction

Synthetic patient 'Owens, Carla' has an authorization for 12 PT visits; 11 are used. From the latest PT progress note (functional scores, goals) request an extension of 8 visits over 4 weeks in the sandbox portal, attaching the progress note and plan of care.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: multi · Cross-app type · Text & forms click · Point & click
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app
Proposed difficulty: 3 / 5

Proposed verifier

Portal extension linked to the existing auth; units 8 and date range 4 weeks from the last authorized date; functional scores in the form match the note; 2 attachments correct. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

25% linked extension; 25% units and dates; 30% functional scores; 20% attachments

R09.03.01.04-T14 Clear a mixed prior-authorization worklist across two payer portals

Original instruction

The EHR worklist 'PA Today' has 10 synthetic cases (imaging, DME, specialty drugs) for payers Acme Health (portal) and Beta Care (fax-only). For each: determine whether PA is needed, submit through the right channel with chart evidence, or hold and task the provider when documentation is missing. Update each worklist item with outcome and reference.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: multi · Cross-app type · Text & forms click · Point & click
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app long · Long-horizon
Proposed difficulty: 5 / 5

Proposed verifier

Per case gold action (submit/no-PA-needed/hold) and channel; submissions field-checked as in T01/T07; holds have provider tasks; worklist items updated. Score = mean per-case score. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

30% cases 1-3; 30% cases 4-6; 40% cases 7-10 (equal share per case, worklist order)

R09.03.01.04-T15 Hold an incomplete request and message the provider for missing information

Original instruction

A PA for synthetic patient 'Hughes, Ben' (knee arthroscopy) is queued. The payer requires documented failure of 3 months of conservative care and an MRI report, but the chart has only 5 weeks of PT and no MRI. Do not submit; send an EHR message to the ordering provider listing exactly what is missing and set the work item to 'Pending info'.

Platforms: web · Any OS (web)
Applications: HealthAdminBench-style apps · payer portals (sandbox)
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: nav · Pan/zoom/scroll type · Text & forms click · Point & click
Work product: WP08 · App/system state
Conditions: clarify · Ask when unclear
Proposed difficulty: 3 / 5

Proposed verifier

No portal submission exists; EHR message to the correct provider names both missing elements (keyword match); work item status 'Pending info'. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

40% no submission; 40% message content and recipient; 20% status

R09.03.01.04-T16 Request an out-of-network gap exception

Original instruction

Synthetic patient 'Silva, Ana' needs pediatric cardiothoracic surgery not available in-network within 60 miles. In the sandbox portal submit a network gap exception with the provider's TIN/NPI from the referral, distance evidence from input/network_search.pdf, and clinical urgency from the cardiology note; record the case ID in the EHR referral.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: multi · Cross-app type · Text & forms click · Point & click
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app
Proposed difficulty: 4 / 5

Proposed verifier

Exception record: provider TIN/NPI exact, nearest in-network distance value matching the PDF, urgency field and diagnosis exact, 2 attachments; EHR referral updated. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

30% provider identifiers; 25% distance evidence; 25% clinical fields; 20% EHR update

R09.03.01.04-T17 Appeal only the denials that are still within the filing window

Original instruction

input/denials.csv lists 9 denied claims with denial dates and payers. Using each payer's appeal deadline from the sandbox portals' policy pages, determine which are still appealable as of the sandbox date, submit first-level appeals for those with the template reason text, and write output/appeal_log.csv (claim, deadline, action).

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: nav · Pan/zoom/scroll type · Text & forms multi · Cross-app
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app
Proposed difficulty: 4 / 5

Proposed verifier

Appeal set equals the 5 in-window claims; no appeals on expired ones; deadlines in the log exact; each appeal linked to its claim. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

30% deadlines; 50% correct appeal set; 20% log consistent

R09.03.01.04-T18 Control pair of T01: submit the lumbar MRI request through an X12 278 API

Original instruction

Control pair of T01. Using the sandbox payer's X12 278 REST endpoint (credentials in input/api.json) and the EHR's FHIR API, submit the same MRI lumbar spine prior-authorization request for 'Alvarez, Tomas' with the same clinical answers and attachments, and write the returned reference number to output/ref.txt.

Platforms: lin · Linux mac · macOS
Applications: payer portals (sandbox) · FHIR API
Interfaces: api · API/SDK
GUI need · task setting: AP · API-sufficient
GUI need · ordinary access: AP · API-sufficient
Interaction primitives: code · Code & commands
Work product: WP08 · App/system state
Conditions: None declared
Proposed difficulty: 3 / 5

Proposed verifier

Same submission checks as T01 against the payer DB (codes, answers, attachments) enabling GUI-vs-API comparison; reference returned matches DB.

Proposed partial credit

25% codes; 35% answers; 20% attachments; 20% reference

R09.03.01.04-T19 Recover from a portal session timeout without duplicating a submission

Original instruction

Submit a PA for synthetic patient 'Becker, Tom' (cardiac MRI) in sandbox portal 'Acme Health'. The portal is configured to expire your session during the attachment step. Log back in, find the saved draft or check whether the request went through, and finish so exactly one complete request exists.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: type · Text & forms click · Point & click nav · Pan/zoom/scroll
Work product: WP08 · App/system state
Conditions: interrupt · Interruptions
Proposed difficulty: 4 / 5

Proposed verifier

Exactly one submitted case for the patient and CPT; fields and attachments complete; abandoned duplicate drafts deleted or none created; EHR reference recorded. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

40% exactly one case; 40% complete fields/attachments; 20% EHR reference

R09.03.01.04-T20 Complete a dynamic pharmacy PA questionnaire

Original instruction

In the sandbox ePA portal (CoverMyMeds-style), open the request for semaglutide for synthetic patient 'Turner, Joy'. Answer the payer's dynamic question set (answers unlock follow-up questions) using A1c history, BMI, current therapy and contraindications from the EHR, then send to plan.

Platforms: web · Any OS (web)
Applications: payer portals (sandbox) · HealthAdminBench-style apps
Interfaces: brow · Browser
GUI need · task setting: G3 · GUI-only
GUI need · ordinary access: G2 · GUI-essential
Interaction primitives: multi · Cross-app click · Point & click type · Text & forms
Work product: WP08 · App/system state
Conditions: multiapp · Multi-app
Proposed difficulty: 3 / 5

Proposed verifier

Final answer set (including branched follow-ups) equals gold path for the patient's facts; request state 'Sent to plan'; no contradictory answers. The agent holds no payer FHIR/API credentials (unlike control T18) and the VM has no shell; the portal DB tags each record's channel, so only browser-session entries count.

Proposed partial credit

70% answers on gold path; 15% no contradictions; 15% sent

Mapped research references

Existing benchmark-to-class links from the research catalog. They are not record-level annotations, executions or product endorsements.

HealthAdminBench

Prior authorization, appeals & claims

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Mapped research references

In this workflow family