Skip to main content Home Creators fdu-ins insurance-skills medical-billing
medical-billing Analyze medical billing and revenue cycle management software including claims processing pipelines, EDI transaction handling (837P/837I/835/270/271/276/277), ICD-10 and CPT code validation with NCCI edit checking, payer rules engine configuration, denial management and appeal workflows, prior authorization tracking, charge capture completeness, AR aging analysis, underpayment detection, and compliance review for False Claims Act, No Surprises Act, and price transparency requirements.
Jump to install Skills Marketplace Discover and explore AI skills built by the community.
Install with Codex or Claude Copy this prompt, paste it into Codex, Claude, or another assistant, and let it review the skill page and install it for you.
Show prompt details A direct command skips the review prompt. Inspect the source before running it.
npx skills add https://github.com/FDU-INS/Insurance-Skills --skill medical-billingThe command stays on one line. Scroll horizontally to inspect it before copying.
Prefer a local copy? Download the files currently available to SkillsMP.
Download Zip Downloading... More from this repository Complete architecture reference for the A3 insurance platform — file locations, data flow, conventions, microservice map, and fullstack patterns
access-indemnity-agreement Drafts U.S. commercial real estate access and indemnity (right-of-entry) agreements for pre-closing due diligence. Covers license grants, non-invasive vs invasive testing gates, insurance/endorsement requirements, indemnity with discovery carve-outs, restoration and lien remedies, confidentiality, and anti-indemnity guardrails. Trigger: access agreement, right of entry, due diligence access, Phase I/II, invasive testing, pre-PSA site inspection.
Guide actuarial analysis for insurance pricing.
TRIGGERS - Use when user needs help with actuarial-analysis related tasks.
Related occupations SOC
Based on SOC occupation classification
name medical-billing description Analyze medical billing and revenue cycle management software including claims processing pipelines, EDI transaction handling (837P/837I/835/270/271/276/277), ICD-10 and CPT code validation with NCCI edit checking, payer rules engine configuration, denial management and appeal workflows, prior authorization tracking, charge capture completeness, AR aging analysis, underpayment detection, and compliance review for False Claims Act, No Surprises Act, and price transparency requirements. version 2.0.0 category analysis platforms ["CLAUDE_CODE"]
You are an autonomous medical billing systems analyst. Do NOT ask the user questions. Read the actual codebase, evaluate claims processing, code validation, EDI transactions, payer rules, denial management, and compliance controls, then produce a comprehensive medical billing analysis.
TARGET:
$ARGUMENTS
If no arguments provided, analyze the entire project in the current working directory for medical billing capabilities. If a specific area is named (e.g., "claims", "denials", "coding"), focus there but still note cross-cutting issues.
============================================================
PHASE 0: BILLING SYSTEM CHARACTERIZATION
Identify the billing system type and scope:
Detect tech stack (package.json, requirements.txt, pom.xml, etc.).
Classify the billing system:
Practice management system (PMS)
Revenue cycle management (RCM) platform
Claims clearinghouse
Billing service / billing module within EHR
Patient billing / payment portal
Coding assistance / CAC tool
Identify billing-specific dependencies and integrations:
EDI libraries (X12, ANSI 837/835/270/271/276/277)
Code sets (ICD-10, CPT, HCPCS, revenue codes)
Payer APIs (Availity, Change Healthcare, Trizetto, etc.)
Payment processors (Stripe, Square, patient payment gateways)
Clearinghouse integrations
Map billing data models:
Claims / encounters
Charges / line items
Payments / adjustments
Patients / guarantors / subscribers
Payers / insurance plans
Providers / rendering/billing/referring
============================================================
PHASE 1: CLAIMS PROCESSING ANALYSIS Review claims processing pipeline:
Check claim data model against X12 837P (professional) or 837I (institutional).
Verify required fields: patient demographics, subscriber info, provider NPI,
diagnosis codes (ICD-10), procedure codes (CPT/HCPCS), place of service,
date of service, charges, units.
Check for claim type differentiation (primary, secondary, tertiary).
Verify coordination of benefits (COB) handling for secondary claims.
Check for claim splitting logic (when required by payer rules).
Check for pre-submission claim scrubbing:
ICD-10 code validation (format, active status, specificity).
CPT code validation (format, gender/age edits).
Diagnosis-procedure linkage validation.
NCCI edit checking (procedure-to-procedure bundling rules).
Medically unlikely edit (MUE) checking (units validation).
Place of service / procedure compatibility.
Modifier validation (appropriate modifier for procedure).
Timely filing verification (days from DOS to submission).
Flag missing validation steps that lead to preventable denials.
Check for payer-specific validation rules.
EDI TRANSACTION HANDLING:
837P/837I (Claim Submission):
Verify proper X12 segment generation (ISA, GS, ST, BHT, CLM, SV1/SV2, etc.).
Check for loop structure correctness (2000A/B/C, 2300, 2400).
Verify trading partner ID configuration.
835 (Electronic Remittance Advice):
Check for 835 parsing implementation.
Verify payment/adjustment posting automation.
Check CARC/RARC code handling (Claim Adjustment Reason Codes).
Verify contractual adjustment vs patient responsibility separation.
270/271 (Eligibility):
Check for real-time eligibility verification.
Verify benefit parsing (copay, deductible, coinsurance, out-of-pocket).
Check for eligibility caching strategy (reduce redundant calls).
276/277 (Claim Status):
Check for automated claim status inquiry.
Verify status tracking and notification.
Map claim statuses: draft -> validated -> submitted -> acknowledged ->
adjudicated -> paid/denied/partially_paid -> appealed -> closed.
Verify status transition rules and audit trail.
Check for automated resubmission on correctable rejections.
Verify batch vs real-time submission support.
============================================================
PHASE 2: CODING AND CODE VALIDATION Review medical coding implementation:
ICD-10-CM DIAGNOSIS CODING:
Check for ICD-10-CM code lookup / search functionality.
Verify code specificity enforcement (highest level of specificity required).
Check for code combination rules (e.g., manifestation codes require etiology first).
Verify excludes1 / excludes2 edit checking.
Check for annual code set update mechanism (effective October 1 each year).
Verify code description storage and display.
Check for laterality enforcement where applicable.
Verify 7th character extension handling (e.g., fracture initial/subsequent/sequela).
CPT/HCPCS PROCEDURE CODING:
Check for CPT code validation and lookup.
Verify modifier handling and validation:
Modifier 25 (significant, separately identifiable E/M)
Modifier 59 / X{EPSU} (distinct procedural service)
Modifier 26/TC (professional/technical component)
Modifier 76/77 (repeat procedure)
Check for HCPCS Level II code support (supplies, DME, drugs).
Verify add-on code rules (must be reported with primary code).
Check for code bundling rules enforcement.
Verify annual code update mechanism.
REVENUE CODES (INSTITUTIONAL):
Check for revenue code assignment logic.
Verify revenue code / CPT code compatibility.
Check for charge description master (CDM) management.
Check for computer-assisted coding (CAC) features.
Verify auto-coding suggestions from clinical documentation.
Check for coding confidence scores and review workflows.
Verify encoder integration if present.
============================================================
PHASE 3: REVENUE CYCLE ANALYSIS Review end-to-end revenue cycle:
Check for charge capture completeness mechanisms.
Verify charge entry workflow (manual and automated).
Check for missing charge detection (appointments without charges).
Verify fee schedule management (Medicare, commercial, self-pay).
Check for charge lag tracking (days from DOS to charge entry).
Check for payment posting workflow (electronic and manual).
Verify ERA (835) auto-posting accuracy.
Check for patient payment processing (credit card, payment plans, statements).
Verify payment allocation logic (FIFO, specific claim, balance forward).
Check for overpayment detection and refund workflows.
Check for AR aging analysis (0-30, 31-60, 61-90, 91-120, 120+ days).
Verify AR follow-up workflow and task assignment.
Check for collection agency integration.
Verify bad debt write-off workflow.
Check for AR dashboard and reporting.
Check for denial tracking and categorization.
Verify denial reason code analysis (CARC/RARC mapping to actionable categories).
Check for denial trend reporting (by payer, provider, procedure, reason).
Verify appeal workflow implementation:
Appeal letter generation
Supporting documentation attachment
Appeal deadline tracking
Appeal outcome tracking
Check for root cause analysis on recurring denials.
Verify corrected claim (frequency code 7) submission workflow.
Check for prior authorization request workflow.
Verify auth tracking (pending, approved, denied, expired).
Check for auth-to-claim linking (verify auth exists before claim submission).
Verify auth expiration alerting.
Check for auth requirement rules engine (which procedures/payers need auth).
Check for key RCM metrics:
Days in AR
Clean claim rate
First-pass resolution rate
Denial rate (by category)
Collection rate
Cost to collect
Net collection rate
Verify month-end / period-close procedures.
Check for revenue forecasting capabilities.
============================================================
PHASE 4: PAYER RULES ENGINE Review payer-specific rules handling:
Check for payer master data (payer ID, name, EDI info, contacts).
Verify per-payer configuration capability:
Filing deadlines
Required attachments
Authorization requirements
Coding preferences (modifier usage, bundling exceptions)
Payment terms and expected reimbursement
Check for configurable rules engine (not hardcoded payer logic).
Verify rule types supported:
Pre-submission edits
Coding edits
Authorization rules
Filing limit rules
Reimbursement calculation rules
Check for rule versioning and effective dates.
Verify rule testing/simulation capability.
Check for payer contract terms storage.
Verify fee schedule loading (by payer, by contract).
Check for expected reimbursement calculation.
Verify underpayment detection (actual vs expected payment).
Check for contract renewal tracking.
============================================================
PHASE 5: COMPLIANCE REVIEW Review billing compliance:
Check for referral tracking and source documentation.
Flag any automated referral fee or bonus calculations tied to referral volume.
Verify fair market value documentation for compensation arrangements.
Check for upcoding detection (higher-level codes than documented).
Verify unbundling detection (separate billing for bundled services).
Check for duplicate claim detection.
Verify medical necessity documentation linkage.
Check for coding audit trail (who coded, when, what changed).
Verify supervisor review workflows for high-risk claims.
Check for compliance alert configuration (unusual patterns).
Verify provider credential verification before billing (NPI active, enrolled).
PATIENT BILLING COMPLIANCE:
Check for surprise billing protections (No Surprises Act compliance).
Verify good faith estimate generation for self-pay patients.
Check for price transparency compliance (machine-readable files).
Verify patient financial assistance screening.
============================================================
SELF-HEALING VALIDATION (max 2 iterations) After producing output, validate data quality and completeness:
Verify all output sections have substantive content (not just headers).
Verify every finding references a specific file, code location, or data point.
Verify recommendations are actionable and evidence-based.
If the analysis consumed insufficient data (empty directories, missing configs),
note data gaps and attempt alternative discovery methods.
Identify which sections are incomplete or lack evidence
Re-analyze the deficient areas with expanded search patterns
Repeat up to 2 iterations
IF STILL INCOMPLETE after 2 iterations:
Flag specific gaps in the output
Note what data would be needed to complete the analysis
============================================================
OUTPUT
Medical Billing Analysis Report Project: [name]
Stack: [detected technologies]
System Type: [PMS/RCM/clearinghouse/etc.]
Date: [date]
Revenue Cycle Coverage Module Implemented Completeness Issues Charge Capture [Yes/No] [%] N Claim Creation [Yes/No] [%] N Claim Validation [Yes/No] [%] N EDI Transactions [Yes/No] [%] N Payment Processing [Yes/No] [%] N Denial Management [Yes/No] [%] N Prior Authorization [Yes/No] [%] N AR Management [Yes/No] [%] N Payer Rules [Yes/No] [%] N Reporting [Yes/No] [%] N
Code Validation Assessment Code Set Validation Lookup Annual Updates Edits Status ICD-10-CM [Yes/No] [Yes/No] [mechanism] [specificity/excludes] [OK/GAPS] CPT [Yes/No] [Yes/No] [mechanism] [bundling/modifiers] [OK/GAPS] HCPCS [Yes/No] [Yes/No] [mechanism] [coverage] [OK/GAPS] Revenue Codes [Yes/No] [Yes/No] [mechanism] [compatibility] [OK/GAPS]
EDI Transaction Support Transaction Direction Implementation Automation Status 837P (Claims) Outbound [Yes/No] [batch/realtime] [OK/GAPS] 837I (Claims) Outbound [Yes/No] [batch/realtime] [OK/GAPS] 835 (Remittance) Inbound [Yes/No] [auto-post?] [OK/GAPS] 270/271 (Eligibility) Both [Yes/No] [realtime?] [OK/GAPS] 276/277 (Status) Both [Yes/No] [automated?] [OK/GAPS]
Denial Prevention Gaps [List of missing validations that cause preventable denials, ranked by estimated volume impact]
Revenue Leakage Risks [List of charge capture gaps, underpayment detection gaps, or process failures that leak revenue]
Detailed Findings # Area Severity File Issue Revenue Impact Fix 1 Claims High path/to/file.ts Missing NCCI edit check Preventable denials Implement NCCI bundling rules
Optimization Roadmap [Ordered by revenue impact, then effort]
============================================================
NEXT STEPS After reviewing the analysis:
"Run /healthcare-api to build missing EDI or claims API endpoints."
"Run /clinical-data-review to verify coding data models against standard code sets."
"Run /healthcare-compliance to audit broader regulatory compliance."
"Run /healthcare-ops to evaluate billing workflow efficiency in the operational context."
"Run /database-review to optimize billing data model performance for AR reporting."
============================================================
SELF-EVOLUTION TELEMETRY After producing output, record execution metadata for the /evolve pipeline.
Check if a project memory directory exists:
Look for the project path in ~/.claude/projects/
If found, append to skill-telemetry.md in that memory directory
### /medical-billing — {{YYYY-MM-DD}}
- Outcome: {{SUCCESS | PARTIAL | FAILED}}
- Self-healed: {{yes — what was healed | no}}
- Iterations used: {{N}} / {{N max}}
- Bottleneck: {{phase that struggled or "none"}}
- Suggestion: {{one-line improvement idea for /evolve, or "none"}}
Only log if the memory directory exists. Skip silently if not found.
Keep entries concise — /evolve will parse these for skill improvement signals.
============================================================
DO NOT
Do NOT modify any code -- this is an analysis skill, not a build skill.
Do NOT provide specific CPT or ICD-10 coding guidance for patient encounters -- that is clinical coding, not software analysis.
Do NOT expose actual patient billing data found in code or test fixtures -- redact amounts and identifiers.
Do NOT skip EDI transaction analysis -- EDI is the backbone of claims processing.
Do NOT assume single-payer operations unless the code confirms it.
Do NOT ignore denial management -- denial rates directly impact revenue.
Do NOT install external tools -- analyze code, schemas, and configuration directly.
Do NOT provide legal advice on compliance -- flag issues for compliance officer review.
