appeals

name	appeals
description	Use when a provider needs to generate an appeal letter for a denied insurance claim, check filing deadlines, validate appeal components, or save completed appeal letters to S3 with presigned download URLs.

Appeals

When to use this skill

• Provider needs to appeal a denied claim
• Check if the filing deadline for an appeal is still open
• Generate a compliant appeal letter with clinical rationale
• Validate appeal components (NPI, CARC/RARC codes, required fields)
• Save a finalized appeal letter and get a download link

MCP Servers Used

• AgentCore Gateway — for payer rules knowledge base (denial codes, filing requirements, medical necessity evidence)

Workflow: Generate Appeal Letter

Step 1: Check filing deadline

Tool: check_appeal_deadline

• Input: payer_name, denial_date (YYYY-MM-DD), appeal_level (first_level | second_level | external_review | peer_to_peer)
• Output: deadline date, days remaining, urgency classification
• STOP if deadline has passed — inform provider of options (external review, state insurance commissioner)

Step 2: Gather denial details

Retrieve from provider or system:

• Claim ID, denial date, denial reason code (CARC), remark codes (RARC)
• Payer name, authorization number (if applicable)
• Patient demographics (name, DOB, member ID)
• Provider info (name, NPI, contact)

Step 3: Research payer rules via Gateway KB

Use Gateway knowledge base tools to look up:

• Payer-specific appeal requirements for the denial reason code
• Medical necessity criteria for the denied service
• Required supporting documentation

Step 4: Draft appeal narrative

Generate the letter body (HTML) including:

• Clinical rationale addressing the specific denial reason
• Evidence of medical necessity
• References to payer policy and clinical guidelines
• Specific remedy requested

Step 5: Validate and assemble

Tool: validate_and_assemble_appeal

• Validates all required fields, NPI format (10 digits), CARC code validity
• Checks clinical rationale completeness
• Assembles compliant HTML letter if all validations pass
• Returns validation errors if any component is missing or malformed

Step 6: Save and deliver

Tool: save_appeal_letter

• Saves validated HTML to S3 (appeals/{claim_id}/{timestamp}-appeal.html)
• Returns presigned URL (1-hour expiry) for download

Key Conventions

• Always check deadline BEFORE generating the letter
• Appeal levels: First Level, Second Level, External Review
• NPI must be exactly 10 digits
• CARC codes must be valid numeric codes (e.g., "50", "197")
• Clinical rationale must specifically address the denial reason — generic statements will fail validation
• Letter body must be HTML format
• Presigned download URLs expire after 1 hour