Total Suspect Records
0
All flagged records (run agent to narrow)
Suspected Claims Count
0
Across all 0 records (run agent to narrow to true positives)
Suspected Claims Amount
$0
Sum of Claims Paid across all records
rule-12-sop-v1.pdf· uploaded Jun 8, 2026
1.Validate NPI is active in NPPES registry
2.Identify the provider's specialty cluster (peer group)
3.Pull network IDs from at least 3 peer providers in the same ZIP3 + specialty
4.Compare suspect provider's network list to peer median
5.Flag as TRUE POSITIVE if missing ≥1 network present in ≥60% of peers
6.Cross-check recent claims (90-day) for activity under the missing network
7.If recent claims found under missing network → escalate as FALSE POSITIVE (data lag)
8.Confirm provider is not in an exclusion list (terminated / opted-out)
9.Claims evidence check — CLAIMS_CHECK_S = 'Claims Found - PAR' AND confidence ≥ 90% → TRUE_POSITIVE
10.Assign confidence score and write recommended action
| Verdict | NPI | Org | Provider | Taxonomy | Specialty | Address | Ntwk Owner | Networks | Dir Display | PARG | Claims Check | Claims # | Claims Paid | Conf. | Suggested Value | Suggested Type | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No records match this filter. | |||||||||||||||||