snf-appeal-supplement

name

snf-appeal-supplement

description

Draft a cited Medicare/insurance appeal supplement document from aggregated SNF records findings. Pulls from *_HotItems.md and *_Findings.md produced by the snf-review pipeline and produces a structured .docx appeal narrative with APPEAL-tagged evidence, LTC-DISPUTE rebuttal, and QUALITY/Medicaid collateral. Use when the user says "/snf-appeal-supplement", "draft the appeal supplement", "turn these findings into an appeal brief", or "write the reconsideration brief from the hot items".

SNF Appeal Supplement

Produce a polished, cited appeal supplement document from aggregated findings. This runs AFTER /snf-review has written *_Findings.md and *_HotItems.md.

Inputs to collect

1. Findings directory — where the roll-up files live (default: the --out-dir from /snf-review).
2. Prefix — the same prefix used for the roll-ups (e.g., FacilityShortName).
3. Appeal target — which payer/appeal this is for (the Medicare Advantage plan or other payer, the Medicare QIO, or the plan's delegated utilization-review vendor) and the case/authorization number if known.
4. Appeal level — first-level reconsideration, second-level QIO, ALJ, etc. Drives tone and length.
5. Termination rationale to rebut — the denial letter's stated reason. Verbatim if possible. Drives which hot items get foregrounded.
6. Patient identifiers — name, DOB, member ID (for the supplement header only; not repeated in the chat).

Preparation

1. Read ${CLAUDE_PLUGIN_ROOT}/skills/snf-records-review/RUBRIC.md to re-load tag semantics.
2. Read <findings-dir>/<prefix>_HotItems.md — these are the value-3 findings pre-formatted.
3. Read <findings-dir>/<prefix>_Findings.md — the master tagged index.
4. Read <findings-dir>/<prefix>_Timeline.md — sorted chronology.
5. Read <findings-dir>/<prefix>_Gaps.md — records gaps. Decide whether to acknowledge or withhold; if any gap is load-bearing against the facility, call it out in the supplement.

Supplement structure

Use the docx skill to produce the final document. Structure:

1. Header block — patient name, DOB, member ID, facility, dates of service, appeal level, case number, termination-effective date.
2. Summary of position — 3-5 sentence framing. Lead with the business outcome: continued skilled need / reversal of termination / overturn of peer review determination.
3. Rebuttal of stated rationale — quote the payer's stated reason, then march through APPEAL-tagged hot items that directly contradict it. Each citation: Source: <filename> p.<page>, brief author/role, verbatim quote, strategic relevance.
4. Clinical instability and skilled need — APPEAL-tagged findings not yet used: desats, med titrations, infection signs, therapy progress with quantified deficits, MDS assessments.
5. LTC narrative rebuttal (include only if LTC-DISPUTE findings exist) — patient's verbatim discharge goal, timeline of LTC-oriented entries vs. family communications, contradictions in same-day entries.
6. Collateral concerns (brief, only if material to the appeal) — MEDICAID unauthorized filing, QUALITY events that show facility bias in documentation.
7. Records gaps noted — short, only if withholding records has actually prejudiced the appeal.
8. Conclusion and relief requested — specific ask: reverse termination, retroactively reinstate coverage from , remand for peer review with full record, etc.

Drafting guardrails

• Every factual claim MUST be cited to a source file + page number that came from the findings.
• Preserve verbatim quotes from the findings — don't paraphrase clinical notes.
• Do NOT introduce new clinical claims or interpretations that aren't in the findings.
• Do NOT give medical or legal advice — frame as "the record shows" and "the following evidence supports," not "the patient needed X."
• Write in first person as the appellant / POA / authorized representative where appropriate. Use the case profile's canonical authority block if available. Tone: measured, specific, unintimidated.
• Federal authorities apply in every state and may be cited directly: 42 CFR 409.31–409.35 (skilled-level criteria), 42 CFR 483.21(c) (discharge planning), 42 CFR 483.25 (quality of care), the Medicare Benefit Policy Manual Ch. 8, and Jimmo v. Sebelius (no failure-to-improve/plateau denial). Do not label these as state-specific.
• State-specific citation marker — canonical pattern for this plugin. Any state statute, state administrative code, state agency name, or state waiver-program name (for example a state HCBS waiver such as Ohio's PASSPORT) must be written in the draft as <citation> [user: verify before submission] — that exact bracketed string, lower-case, so the user can find every one with a single search. Remove a marker only after the user confirms the citation and its current section number. If this plugin has no verified reference file for the user's state, do not name a state agency or statute at all; write [user: insert your state's <survey agency / Medicaid agency / POA statute> — verify before submission].

Output

Use the docx skill to produce <findings-dir>/<prefix>_Appeal_Supplement.docx. After writing:

1. Tell the user the file path and a one-paragraph summary of what the supplement argues.
2. List the top 3 citations used (filename + page) so the user can spot-check them.
3. List any hot items that did NOT make it into the supplement and why — the user may want to override.
4. Remind: this is a draft for the user's review and a lawyer/patient advocate's review, not filed work product.