System Flow
Asepha Prism connects contracts, claims, and true-ups through two core agents — CIA for rules and DFA for forecasting.
Input Sources
Network Participation File (NPF)
Crosswalks BIN/PCN/Group to contracts; tags claims with correct PBM contract.
PBM Contracts + Addendums
Source of DIR logic; parsed by Contract Intelligence Agent (CIA).
Claims Data
Live pharmacy claims pulled or uploaded; linked to contract IDs via NPF.
Processing Layer
Contract Intelligence Agent (CIA)
Agent- Label & Parse Contract
- Flag unresolved references to addendums
- Provide certainty levels (max DIR ≤ 5%)
- Write rules table
DIR Forecast Agent (DFA)
Agent- Apply claim-specific logic
- Evaluate claim against contract rules
- Tag with contract ID via NPF
- Generate claim-level DIR forecast
Output Layer
Dashboard – $ and Risk View
Aggregates claim-level forecasts into network DIR exposure.
DIR / True-Up Letter Upload
Feeds variance back to CIA to retrain model.
Retrain Loop