claim-denial-appeal-prep

Claim denial appeal prep

Given denied codes and a payer, find the policy version in effect on the policy as-of date (the date whose policy version applies), pull its criteria, and draft an appeal-letter outline that cites the policy. The user fills in the clinical facts from their own records.

The tools come from the Backwork MCP server. Their names start with backwork_. Some clients add a prefix, for example mcp__plugin_backwork_backwork__backwork_policy_research. If no Backwork tool is available, tell the user to connect Backwork (https://backworkhealth.com/mcp) and stop. Do not answer from general knowledge.

Ground rules

• Research support, not a determination. Do not state that the denial is wrong, that the service was medically necessary, or that the appeal will succeed. The outline shows which policy criteria the record must show. End every answer with: "Confirm the policy version and appeal process with the payer before you file."
• No PHI. Never ask for or accept patient names, member IDs, dates of birth, MRNs, claim numbers, addresses, or chart notes. If the user pastes any, do not repeat it. Ask them to remove it. Use placeholders such as [Member ID] in the letter. Send only codes, payer, state, plan type, policy as-of date, and denial reason codes to the tools.
• Quote only what the tools return. Put policy language in quotation marks only when it is verbatim from tool output. Never write or reconstruct policy text. If the tools did not return the criterion text, write "[Criterion text not returned. Copy it from <source_url>.]"
• Cite from tool output only. Each policy citation needs: policy number (policy_id), title, payer or authority, effective date, and source URL. Add the last-verified date when the tool returns it. A field the tool did not return is written "not returned".
• Inferred codes are not document-backed. A code with source: inferred_title_match is attached because the policy title names the drug. The document does not list the code. Never cite an inferred code as listed in the policy. Tell the user to confirm the code in the document before the appeal relies on it.
• Say when you don't know. If no policy for the payer was in effect on the policy as-of date, say so. Do not build an appeal on a different payer's policy or a policy that took effect after the policy as-of date.