evidence-assemble

Evidence Assemble

Purpose

Build the cited evidence base the appeal will rely on.

When to use

Use after policy-retrieve and before deadline-track and appeal-draft - typical asks are "pull the chart evidence for this appeal", "does the documentation support the billed code", "what in the record answers this denial".

When NOT to Use

Do NOT use when: no policy clause has been retrieved yet (the evidence has nothing to answer) - use policy-retrieve first; the ask is to read a remittance or classify a denial - use denial-classify instead; the ask is to interpret payer policy - use policy-retrieve instead; the ask is to compose the appeal letter - use appeal-draft instead; the ask is to approve or apply a coding change - use deadline-track instead (it enforces that boundary, and no skill applies codes); or the ask is to make the evidence "look stronger" than the chart supports - that is out of bounds, not a task.

Inputs

The clinical record, read through [TO CONFIGURE: clinical record source / EHR connector] with the session's file or connector tool (until it is configured, only the chart_evidence already on the contract is available); original claim and coding; the denial reason; the retrieved policy clause; coding_request (if any).

Steps

1. Read the denial reason and the retrieved policy clause to fix what the evidence has to answer, and name the code being defended: the coding_request's requested code if one exists, otherwise the billed original_code.
2. Gather the clinical notes/results that speak to that question from the configured record source, including any that weaken the appeal.
3. Record each one in chart_evidence.citations[] with note, date, supports_code and a short verbatim excerpt.
4. Set chart_evidence.supports_requested_code true only when a citation in that list names a specific note and date whose supports_code is the code named in step 1; otherwise leave it false.
5. Compare the clause's setting or service type with the claim's (e.g. an inpatient-observation clause against an office E/M code) and record any mismatch as a gap.
6. Hand off to deadline-track (coding decision and clock) and then appeal-draft.