appeal-draft

Appeal Draft

Purpose

Produce the appeal letter text for coordinator review.

When to use

Use after evidence-assemble and after deadline-track has set coding_decision and deadline_status - typical asks are "draft the appeal letter", "write our response to this denial", "redraft it on the original code".

When NOT to Use

Do NOT use when: the denial has not been classified yet ("start an appeal on CLM-..." from a remittance) - use denial-classify instead; policy_citations or chart_evidence are still empty (there is nothing to cite, so drafting would invent the case) - use policy-retrieve or evidence-assemble instead; the ask is to submit, file, fax, e-mail or upload the appeal to a payer portal, or to mark it submitted or closed - that is refused, not delegated; the ask is to draft around a code the chart does not cite; or the ask is for the deadline, queue order or coding decision - use deadline-track instead.

Inputs

denial; policy_citations; chart_evidence (with its citations); deadline_result (coding_decision, deadline, days_remaining, deadline_status); config/payer-appeal-windows.json (appeal level).

Steps

1. Confirm policy_citations and chart_evidence are populated. If deadline_result is absent, or its provenance.computed_as_of is not today, run deadline-track first (tool: python3 base/scripts/deadline_engine.py --question <contract.json> --payers config/payer-appeal-windows.json --out <result.json>, no --today) and use its result.
2. Read deadline_result.deadline_status: if expired or urgent, put that status, the deadline and the day count in the first line of the draft header and in the coordinator notes; if unconfigured, say no deadline could be computed.
3. Draft the letter at the level carried in config for the payer (config/payer-appeal-windows.json payers[payer].level, payer name matched case-insensitively).
4. Cite the policy clause_id and every chart_evidence citation used, inline, in the forms "(clause_id)" and "(note, date)". If the clause text is not on the contract, cite it by clause_id only and say the wording is not on file.
5. If coding_decision is refused_evidence_gap, draft on the original, chart-supported code only and state in the coordinator notes that the coding question is open for human decision.
6. Return the letter as a draft for coordinator review before anything is sent - never as a sent or filed item.