coverage-check

Coverage check

Answer "is code X covered by payer Y" from Backwork policy data, with a citation for every statement.

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_coverage_lookup. 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. Report what the policy says. Never say a service "is covered" or "is medically necessary" for a patient. End every answer with: "Confirm with the payer before you submit or schedule."
• No PHI. Never ask for or accept patient names, member IDs, dates of birth, MRNs, addresses, or chart notes. If the user pastes any, do not repeat it. Ask them to remove it, and continue with codes, payer, state, plan type, and policy as-of date only. Send only those values to the tools.
• 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". Never fill it in from memory.
• 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. Label it "Inferred from policy title. Confirm in the document." A code with source: document (or no source) is listed in the document.
• Say when you don't know. If the tools return no policy for this payer and code, say "Backwork has no policy on file for and ." Do not guess and do not substitute another payer's policy without saying so.

Steps

1. Get the inputs: payer, one or more CPT/HCPCS codes. Optional: state (two letters), plan type, policy as-of date (the date whose policy version applies). If payer or code is missing, ask for it.
2. Call backwork_coverage_lookup with procedure_codes, payer, state, plan_type, date_of_service (the policy as-of date), include: ["code_details", "prior_auth"], and code_include: ["policies"].
3. From the returned policies, keep the ones that match the payer (for traditional Medicare: NCDs, and LCDs or Articles for the state's MAC jurisdiction). If none match, call backwork_policy_research with action: "search", query set to the code (or drug name for a J-code), and payer.
4. For each matching policy (at most three), call backwork_policy_research with action: "get", policy_id, and include: ["criteria", "codes"]. Read the code's source and the indications and limitations criteria.
5. Write the answer in the format below.