## Business Rule Extractor™ — Output --- ### PRE-FLIGHT CHECK | Check | Result | |---|---| | DOMAIN_SOURCE present? | ✅ YES | | DOMAIN_SOURCE parseable? | ✅ YES — 4 rule candidates identified | | RULE_SCOPE specified? | ✅ ALL | | DOMAIN_CONTEXT conflict? | ✅ NONE — source consistent with stated domain | --- ## SECTION 1 — DOMAIN PROFILE ``` DOMAIN: Health Insurance Claims Processing RULE SCOPE: ALL (OPERATIONAL, DATA, DECISION, CONSTRAINT, TEMPORAL) SOURCE TYPE: Policy narrative OUTPUT DETAIL: STANDARD RULE CANDIDATES IDENTIFIED: 4 EXPLICIT: 3 INFERRED: 1 AMBIGUOUS: 0 GAPS: 2 ``` --- ## SECTION 2 — EXTRACTED RULES --- **── RULE T-01 ────────────────────────────────────────────────────** ``` TYPE: TEMPORAL STATE: EXPLICIT SUBJECT: Claims — all submitted claims CONDITION: When a claim is submitted more than 30 days after the incident date ACTION: Claim must NOT be processed under standard processing; it is ineligible SOURCE: "Claims submitted after 30 days from incident date are ineligible for standard processing." CONFIDENCE: HIGH BASIS: Direct statement with explicit threshold (30 days), trigger condition (submission date vs. incident date), and outcome (ineligibility for standard processing). ``` --- **── RULE T-02 ────────────────────────────────────────────────────** ``` TYPE: TEMPORAL STATE: EXPLICIT SUBJECT: Urgent claims — physician-flagged CONDITION: When a claim has been flagged as urgent by a physician ACTION: Claim MUST be reviewed within 48 hours of flagging SOURCE: "Urgent claims flagged by a physician must be reviewed within 48 hours." CONFIDENCE: HIGH BASIS: Direct statement with explicit actor (physician), qualifying condition (urgent flag), and deadline (48 hours). Review start/trigger point not stated — see GAP-01. ``` --- **── RULE C-01 ────────────────────────────────────────────────────** ``` TYPE: CONSTRAINT STATE: EXPLICIT SUBJECT: Adjusters CONDITION: When a claim value exceeds $50,000 ACTION: Adjuster MUST NOT approve the claim without senior sign-off; senior approval is required before approval can be issued SOURCE: "Adjusters may not approve claims exceeding $50,000 without senior sign-off." CONFIDENCE: HIGH BASIS: Direct prohibition with explicit subject (adjusters), monetary threshold ($50,000), and required compensating control (senior sign-off). "Senior" is undefined — see GAP-02. ``` --- **── RULE D-01 ────────────────────────────────────────────────────** ``` TYPE: DECISION STATE: INFERRED SUBJECT: Claims — submitted after 30-day window (see T-01) CONDITION: When a claim is ineligible for standard processing ACTION: An alternative processing path, exception workflow, or rejection outcome MUST exist to handle the claim; the claim cannot simply be discarded without disposition SOURCE: Structurally implied by T-01 — ineligibility for standard processing presupposes an alternate outcome exists; no narrative dead-end is operationally viable CONFIDENCE: MEDIUM BASIS: Structural implication from process logic. Standard processing exclusion without a defined alternate path is not operationally complete. No explicit alternate path is stated in source — see GAP-01 extension. ``` --- ## SECTION 3 — CONFLICTS ``` NO RULE CONFLICTS DETECTED ``` T-01 and T-02 operate on different claim populations (late claims vs. urgent claims) and do not overlap in a contradictory way. No rules in the extracted set directly contradict or partially override one another. > **Advisory note:** T-01 and T-02 may interact in edge cases — e.g., an urgent physician-flagged claim submitted after 30 days. Neither rule addresses this intersection. This is logged as GAP-01 below, not as a conflict, since neither rule explicitly overrides the other in this scenario. --- ## SECTION 4 — GAPS **── GAP-01 ────────────────────────────────────────────────────────** ``` TYPE: MISSING_RULE LOCATION: T-01 (30-day ineligibility) and T-02 (48-hour urgent review) DESCRIPTION: Two rules are unresolved: (a) No rule defines what happens to claims ineligible under T-01 — no rejection, appeal, exception, or alternate routing path is specified. (b) No rule addresses the intersection of T-01 and T-02: what applies when a claim is both late (>30 days) AND physician-flagged urgent? It is undefined whether urgency overrides the 30-day ineligibility threshold. (c) The 48-hour clock in T-02 has no defined start point (flagging time, receipt time, business hours basis). IMPACT: BLOCKING — without (a) and (b), claims processing cannot be fully executed for out-of-window or dual- condition claims. (c) is ADVISORY for SLA enforcement. ``` --- **── GAP-02 ────────────────────────────────────────────────────────** ``` TYPE: UNDEFINED_ENTITY LOCATION: C-01 ("senior sign-off") DESCRIPTION: "Senior" is not defined in the source. No role title, seniority level, job code, or authority threshold is provided. It is unknown whether "senior" refers to a Senior Adjuster, Claims Manager, VP-level authority, or another role classification. IMPACT: ADVISORY — C-01 is usable as a constraint but cannot be operationalized or enforced until "senior" is mapped to a defined role in the organization's authority matrix. ``` --- ## SECTION 5 — RULE SUMMARY TABLE ``` RULE ID | TYPE | STATE | CONFIDENCE | CONFLICT | GAP ──────────────────────────────────────────────────────────────── T-01 | TEMPORAL | EXPLICIT | HIGH | NONE | GAP-01 T-02 | TEMPORAL | EXPLICIT | HIGH | NONE | GAP-01 C-01 | CONSTRAINT | EXPLICIT | HIGH | NONE | GAP-02 D-01 | DECISION | INFERRED | MEDIUM | NONE | GAP-01 ``` --- ## SECTION 6 — CONFIDENCE REGISTER + REFUSED INFERENCES **Confidence Register** ``` RULE T-01 Confidence: HIGH Basis: 3 signals — explicit threshold, explicit subject, explicit outcome RULE T-02 Confidence: HIGH Basis: 3 signals — explicit actor, explicit condition, explicit deadline RULE C-01 Confidence: HIGH Basis: 3 signals — explicit subject, explicit threshold, explicit prohibition RULE D-01 Confidence: MEDIUM Basis: 1 signal — structural implication from T-01; no direct source statement ``` --- **Refused Inferences** The following were **NOT** inferred due to insufficient evidence: ``` × That late claims (T-01) are automatically rejected — Source states ineligibility for "standard processing" only; alternate handling (exception, appeal, manual review) is not ruled out. Classifying as rejection would exceed source evidence. × That "senior sign-off" in C-01 refers to a specific named role (e.g., Senior Adjuster, Claims Manager) — Source uses the term without definition; mapping to any role would be fabrication. Logged as GAP-02. × That the 48-hour window in T-02 applies only during business hours — Source states "48 hours" without qualification; imposing a business- hours interpretation is not supported by source text. × That physician flagging in T-02 requires written documentation — Source states "flagged by a physician" with no format or medium specified; requiring written form would exceed source evidence. ``` --- **Open-world notice:** Rules extracted are bounded by the content of the provided source. Additional rules governing claims intake, fraud screening, payment disbursement, appeals, or provider coordination may exist in related policies, system specifications, or regulatory documents not provided. Absence of a rule in this output does not confirm that rule does not exist.