Complete AI Training
Sign inGet my AI kit

Your job's AI kit

Get your AI kit

Tell us who you are and what you do. We show you your kit right away and email you the link: skills, prompts, AI agents, MCP servers and courses for your job.

500+ jobs ready, and we make a kit for any other job. No payment needed to look.

Share

AI agent for pharmacists

Rejected Claim Resolution Agent

Turn each rejected claim into a paid claim or a clear next step for the patient.

AdministrationAutomationHealthcareOperations
See how it worksGet access
Rejected Claim Resolution Agent: what goes in, what the agent does and what you get

What it does

A rejected claim leaves a patient waiting at the counter or going home without medicine. This agent reads each rejection code and picks the likely fix: a quantity limit, a days supply mismatch, a refill-too-soon, a wrong plan or a missing prior authorization. It tries the fix in a draft claim, for example changing days supply to match the plan, and resubmits it once the pharmacist approves. If the claim still rejects, it reads the new code and tries the next fix. If prior authorization is needed, it drafts the request to the prescriber with the clinical details. It tracks the answer and resubmits when it comes. Edge case: a fix would change the quantity dispensed, so the agent shows the pharmacist and does not apply it silently.

How it works

Follow the arrows from top to bottom. The orange dashed arrow is the loop: when a check fails, the agent goes back and tries again.

Start and resultWhat it doesA check on its own workWaits for your OKGoes back and retries
ApprovedYes, continueApprovedYes, continueNoNo 1 STARTS WHEN A claim is rejected 2 USES A TOOL Read the rejection code and plan rules 3 DOES Choose the smallest fix that keeps the prescriptionas written 4 YOU APPROVE Pharmacist approves any change to quantity or dayssupply 5 USES A TOOL Resubmit the claim with the fix 6 CHECKS THE RESULT Was the claim paid? If not: read the new code and choose the next fix, up to3 tries. Back to step 3. 7 DOES If prior authorization is needed, draft the request 8 YOU APPROVE Pharmacist approves the prescriber request 9 USES A TOOL Track the answer and resubmit 10 CHECKS THE RESULT Did the answer arrive and the claim pay? If not: chase the prescriber after 24 hours and offerthe patient options. Back to step 8. 11 RESULT Paid claim or patient options noted
Read the steps as a list
  1. A claim is rejected
  2. Read the rejection code and plan rules
  3. Choose the smallest fix that keeps the prescription as written
  4. Pharmacist approves any change to quantity or days supplyThe agent waits here for your OK.
  5. Resubmit the claim with the fix
  6. Was the claim paid?If not: read the new code and choose the next fix, up to 3 tries. Back to step 3.
  7. If prior authorization is needed, draft the request
  8. Pharmacist approves the prescriber requestThe agent waits here for your OK.
  9. Track the answer and resubmit
  10. Did the answer arrive and the claim pay?If not: chase the prescriber after 24 hours and offer the patient options. Back to step 8.
  11. Paid claim or patient options noted

How it decides

It maps each code to the smallest fix that keeps the prescription as written and tries fixes in order of simplicity.

  • Never change the drug or dose
  • Try at most 3 fixes before moving to prior authorization
  • Use patient cash price options only after approval
  • Escalate refill-too-soon rejections to the pharmacist

Make it yours

Every agent is a starting point. You choose these settings for your own situation.

  • Maximum fix attempts (default 3)
  • Prescriber chase time (default 24 hours)
  • Which codes to auto-draft
  • Patient message wording

What keeps you in control

It always asks you first

  • Pharmacist approves quantity or days supply changes
  • Pharmacist approves prescriber requests
  • Pharmacist approves telling the patient about options

Hard limits

  • Never alter the prescription
  • Never contact a prescriber without approval

It stops when

  • Done: claim paid
  • Stop: patient chooses another route, log it

Set it up

We guide you through the set-up, step by step

Members get the full set-up guide for this agent. No technical skills needed: you copy, paste and upload.

10 minto set it up in your AI
5 AIsChatGPT, Claude, Copilot, Gemini, Grok
  • One set of instructions to paste into your AI, with the clicks for ChatGPT, Claude, Microsoft 365 Copilot, Gemini and Grok
  • The agent then walks you through connecting your own data, one source at a time
  • A downloadable copy with the flow chart, the rules and the full guide
Get access to this agent

An example run

What happensA claim for 90 tablets rejected with a quantity limit of 30 days. The agent changed the days supply to match 90 tablets and tried again. The claim failed with a code for prior authorization. The agent drafted a request with the diagnosis and prior therapies. The pharmacist approved it, the prescriber replied the next day, and the resubmitted claim paid.

More agents for pharmacists

Risk management · Healthcare

Supplement and Medication Interaction Screening Agent

Every client's combinations are checked and any risk is passed to a prescriber before the client continues.

10 steps1 check5 jobs
Communication · Healthcare

Adherence Gap Outreach Agent

Bring lapsed patients back on therapy, or document why they stopped.

10 steps2 checks1 job
Administration · Compliance

Immunization Administration and Reporting Agent

Get every vaccine dose recorded correctly and accepted by the registry.

9 steps2 checks1 job
Risk management · Healthcare

Opioid Safety Review Agent

Make sure each opioid fill is within safe limits, or the prescriber has reviewed it.

10 steps2 checks1 job