claims-assembly

name	claims-assembly
description	Use when a provider needs to validate claim data and assemble an EDI 837P professional claim, check payer-specific validation rules, or verify HIPAA 5010 compliance before submission.

Claims Assembly

When to use this skill

• Provider needs to assemble a professional claim (837P) for submission
• Validate claim data against HIPAA 5010 requirements
• Look up payer-specific validation rules before assembly
• Check EDI schema requirements for specific fields
• Verify NPI, ICD-10-CM, CPT/HCPCS code formats

MCP Servers Used

• Bedrock Knowledge Base — for payer-specific validation rules, HIPAA compliance rules, and EDI schema requirements

Workflow: Assemble EDI 837P Claim

Step 1: Gather claim data from provider

Required components:

• Billing Provider: name, NPI, tax_id, taxonomy_code, address, contact_phone
• Subscriber: first_name, last_name, member_id, date_of_birth (CCYYMMDD), gender (M/F/U), group_number
• Payer: name, payer_id, address
• Diagnosis Codes: 1-12 ICD-10-CM codes with descriptions
• Service Lines: procedure_code (CPT/HCPCS), charge_amount, units, date_of_service (CCYYMMDD), place_of_service, modifiers, diagnosis_pointers

Optional:

• total_charge, prior_auth_number, referral_number, rendering_provider, facility_npi/name

Step 2: Query validation rules knowledge base

Tool: query_validation_rules

• Input: query (e.g., "Medicare modifier requirements"), rule_type (payer | compliance | schema | all)
• Output: relevant validation rules with relevance scores
• Check payer-specific requirements BEFORE assembly (referral numbers, specific modifiers, timely filing limits)

Step 3: Validate and assemble

Tool: validate_and_assemble_claim

• Input: claim_json (JSON string following the schema)
• Performs deterministic validation:
  • NPI format (10 digits, Luhn check)
  • ICD-10-CM code format (letter + digits, valid range)
  • CPT/HCPCS code format (5-digit numeric or alpha-numeric)
  • Date format (CCYYMMDD, valid calendar date)
  • Charge consistency (total_charge = sum of line charges)
  • Cross-field rules (diagnosis_pointers reference valid indices)
  • Required field presence
• Output: valid (bool), issues (list with severity/field/message), edi_837p (if valid)

Step 4: Review and correct

• If validation fails, present issues to provider grouped by severity (error vs warning)
• Errors block assembly; warnings are advisory
• After corrections, re-validate until clean

Validation Rules Reference

Field	Format	Example
NPI	10 digits	1234567890
ICD-10-CM	A00-Z99.x format	M54.5, E11.65
CPT	5-digit numeric	99213, 72148
HCPCS	Alpha + 4 digits	J1745, G0127
Date	CCYYMMDD	20260115
Gender	M, F, or U	M
Place of Service	2-digit code	11 (office), 21 (hospital)

Key Conventions

• Always query the validation KB for payer rules BEFORE assembling
• Total charge must equal the sum of all service line charges
• Diagnosis pointers are 1-based indices into the diagnosis_codes array
• Maximum 12 diagnosis codes per claim
• At least one service line is required
• Relationship code defaults to "18" (self) if not specified
• Modifiers are ordered (primary, secondary, tertiary, quaternary)