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Simulation · not operational100% synthetic data · the demos’ human decisions were simulated in batch
planlang
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Demo A · run suscripcion-planlang-a-002-200-v1.5 · one real trace

One case, end to end

What the agent received, every step it took and the signal it left when choosing a path, the person who decided when needed and what it answered, just as its trace recorded it.

This run’s human decisions were simulated. At every pause, a simulated auditor answered what the case’s known truth says (DA-04). Cases, members and the benefits plan are synthetic.

The case at a glance

Read as

Reading as leader. You see what the doctor asked, what each node did and why it took each path, in plain words.

Reading as expert. Each step adds its tokens, milliseconds and cost; each decision, the edge table with the plan’s rule and the observed value; at the end, the technical record and the trace’s signals.

A-017normal, excluded

Deniedwith a personmatches the known truth
What should happen

The service is excluded on a legal ground: the agent proposes a denial, a human auditor confirms it and the denial document is issued in two languages.

What happened

Final decision: deny, with a person.

Takes in

  • The doctor’s text
    Referral note. 70-year-old woman. Diagnosis: Cosmetic wish with no functional problem. Seen in the outpatient clinic last week. Request: Cosmetic rhinoplasty. Estimated cost: 1400 synthetic units. Kind regards.
  • The attached orderSYN-P-035 · care hospitalaria · Order signed by the treating doctor.
  • Member: woman, 70 years oldname, ID, medical record, phone and email are masked before the model (decision D1)

Does

7 steps
enrutadorextractorverificador_coberturadecisionpausa_humanaredactorguardia_salida

The doctor requested “Cosmetic rhinoplasty” for a 70-year-old woman. The extractor read the data with 0.95 confidence and nothing was missing. The coverage checker found the service excluded by law (ground a of art. 15 of Law 1751) and proposed to deny. The estimated cost is above the high-cost threshold U2: the case went to an auditor, who decided to deny. The writer drafted the reply with its AI notice, the adverse decision document was issued in Spanish and English and the guard checked the output: no data leaked. It took 11.9 s.

Delivers

  • The reply to the member, with its AI notice
  • The adverse decision document, in Spanish and English
  • The trace, with its fingerprintad75e939df75…
11.9 send to end
7steps
2model calls
6,564tokens
0.0272nominal US$, not billed

Expert

The trace’s technical record

Trace
planlang-trace/v1 · ad75e939df750c664a04307d237704d67681957eb48138462bddd5c3f08d3acd
Run
suscripcion-planlang-a-002-200-v1.5 · variant multiagente · result completo
Errors
provider: none · schema on handoff: no
Known truth
decision negar · must escalate yes · cycles needed 0 · ground a
Case
normal · normal_excluido · seed planlang-a-002

The path, step by step

real · steps and edge decisions

Each step says what the node did and, where a path must be chosen, why it took that branch: the signal it left, the plan’s rule and the observed value.

  1. 1
    enrutadorno model

    Classified the care type: inpatient.

    type enrutador · in 0 · out 0 tokens · 0 ms · US$ 0.000000 · schema retries 0

    neither an emergency nor an exempt service: on to the extractor

    1Signaltipo_atencionRule= urgenciaObservedhospitalariaHolds?noBranch—
    2Signalservicio_exentoRule= trueObservednoHolds?noBranchextractor
  2. 2
    extractor6.0 s · 4,324 tokens

    Read the doctor’s text and turned it into fields, with a stated confidence.

    type modelo · in 4054 · out 270 tokens · 5961 ms · US$ 0.015146 · schema retries 0

    nothing missing: on to the coverage checker

    1Signalproveedor_no_disponibleRule= trueObservednoHolds?noBranch—
    2Signalcampos_faltantes_countRule> 0Observed0Holds?noBranchverificador_cobertura
  3. 3
    verificador_coberturano model

    Applied the benefits plan rules: service excluded, ground a; proposal: deny.

    type regla · in 0 · out 0 tokens · 0 ms · US$ 0.000000 · schema retries 0

  4. 4
    decisionno model

    Checked the plan’s 6 escalation rules, in order.

    type enrutador · in 0 · out 0 tokens · 0 ms · US$ 0.000000 · schema retries 0

    the cost is above U2: on to a person

    1Signalcarga_detectadaRule= trueObservednoHolds?noBranch—
    2Signalsenal_confianzaRule< U1 = 0.75Observed0.95Holds?noBranch—
    3Signalcosto_estimadoRule> U2 = 1000Observed1400Holds?yesBranchpausa_humana
    4Signalcontradiccion_orden_textoRule= trueObservednoHolds?noBranch—
    5SignalpropuestaRule= negarObservednegarHolds?yesBranch—
    6Signaltexas_y_no_aprobar(modo_texas, propuesta)Rulenamed functionObservedmodo_texas = false, propuesta = negarHolds?noBranch—
  5. 5
    pausa_humanano model

    An auditor saw the full case and decided: deny.

    type pausa_humana · in 0 · out 0 tokens · 0 ms · US$ 0.000000 · schema retries 0

  6. 6
    redactor6.0 s · 2,240 tokens

    Wrote the reply to the member, with the AI notice; code assembled the adverse decision document.

    type modelo · in 1421 · out 819 tokens · 5960 ms · US$ 0.012050 · schema retries 0

  7. 7
    guardia_salidano model

    Checked the output: 0 findings, severity 0.

    type regla · in 0 · out 0 tokens · 0 ms · US$ 0.000000 · schema retries 0

The human pause: what the auditor saw

real · interrupt payload

No full denial goes out without a person. The agent stops and hands the auditor the full case: why it stopped, what it read, the original text, the evidence and the counter-evidence.

Why it stopped

The estimated cost is above the high-cost threshold U2.

payload.motivo: Edge 3 of decision: costo_estimado (1400) greater than umbral.U2 (1000).

signal costo_estimado · declared threshold umbral.U2 · applied 1000 · node pausa_humana · step 5 · role auditor

Evidence

  • The benefit plan lists SYN-P-035 as excluded (ground a: Ley Estatutaria 1751 de 2015, art. 15, literal a).
  • Estimated cost 1400 above the high-cost threshold 1000.

Counter-evidence

  • Doubt about what a service covers is resolved in the member's favour (Law 1751, art. 8).
  • Diagnosis SYN-D-30 is consistent with SYN-P-035.

What the extractor read

costo_estimado 1400 · diagnostico SYN-D-30 · procedimiento SYN-P-035 · urgencia no · confidence 0.95

The rest of the case it received

  • Order: SYN-P-035 · care hospitalaria · Order signed by the treating doctor.
  • Coverage: excluded · ground a of art. 15 of Law 1751 · high cost · rules RB-03, RB-04
  • Clarifications: none
What the auditor answered

negar

Simulated auditor: in this batch run it follows the case’s known truth (policy sigue_verdad_conocida). In production a person decides with this same payload.

The reply and the guard

real · salida_final and guardia_salida
What the member receives

Your request for aesthetic rhinoplasty has been denied. The reason is that its main purpose is cosmetic or non-essential, and it is not related to restoring or maintaining functional or vital capacity. A person reviewed this decision. You will receive a document explaining how to file a claim.

Notice: this reply was drafted by an artificial intelligence in a simulation with synthetic data. No denial is issued without review by a person.

Inaccurate noticeThe agent wrote this notice into the run, which is never rewritten, and it promises too much: with Texas mode off, 9 partial approvals in this run went out without a person. It holds for a full denial: from plan v1.5.1 on the agent writes it that way, and this run is from v1.5.

Output guard: fixed rules, no model

Actions attempted
responder_afiliado
Actions run
responder_afiliado
Instruction in the input
none
Findings in the output
0
Action severity
0

The adverse decision document

real · generated by code

Every denial, partial ones included, carries this document, in Spanish and English: code builds it, not the model. It says what was denied, on which ground, by which rule, with which data and which plan version, who decided and how to challenge it.

Adverse decision documentA-017 · planlang-documento-adverso/v1
Service
Cosmetic rhinoplasty · SYN-P-035
Decision
Denied
Ground
Its main purpose is cosmetic or luxury, unrelated to recovering or keeping functional or vital capacity.Ley Estatutaria 1751 de 2015, art. 15, literal a
Rule applied
RB-03 Excluded service: it is denied only by citing its ground under art. 15 of Law 1751, and a person confirms the denial.
Data used
procedimiento SYN-P-035 · diagnostico SYN-D-30 · costo_estimado 1400
Version
plan-demo-a 1.5.0 e1dc89c72a37… · pb-demo-a 2.0.0 aea5fe3ad425…
Decided by
A human auditor. In this batch run the auditor is simulated and follows the case's known truth.
How to challenge it
You can ask for this decision to be reviewed: file a review request with the insurer, with this document, within the legal deadlines; you can also go to Colombia's National Health Superintendency. This simulation has no real procedure.
Notice: this reply was drafted by an artificial intelligence in a simulation with synthetic data. No denial is issued without review by a person.
Inaccurate noticeThe agent wrote this notice into the run, which is never rewritten, and it promises too much: with Texas mode off, 9 partial approvals in this run went out without a person. It holds for a full denial: from plan v1.5.1 on the agent writes it that way, and this run is from v1.5.

complete: yes · languages: es · en · C8: every denial with a complete document in ES and EN

The 18 signals the trace leaves

Expert

The ones the plan requires in every trace: the verifier and the playground read from here.

campos_faltantes_count
0
carga_detectada
no
ciclos_aclaracion
0
contradiccion_orden_texto
no
costo_estimado
1400
decision_final
negar
error_proveedor
—
latencia_total_s
11.92
modo_texas
no
nodos_visitados
enrutador → extractor → verificador_cobertura → decision → pausa_humana → redactor → guardia_salida
pausa_humana
yes
propuesta
negar
proveedor_no_disponible
no
senal_confianza
0.95
servicio_exento
no
severidad_accion
0
tipo_atencion
hospitalaria
tokens
6564