coverage-rights
Insurer denial rates, appeal outcomes by treatment and condition, and appeal rights lookups.
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Insurer denial rates, appeal outcomes by treatment and condition, and appeal rights lookups.
Server tool list (9)
Raw names from tools/list. Only developers need these.
| list_insurers | List tracked U.S. health insurers with whether verified CMS-0057-F prior-authorization metrics are available for each. |
| get_insurer_metrics | Get an insurer's verified CY2025 prior-authorization metrics (denial rate, appeal overturn rate, decision times) from its own CMS-0057-F disclosure, plus contract/plan-level rows where collected. Includes source URLs and scope notes. |
| rank_denial_rates | Insurer prior-authorization denial rates (CY2025), ranked only within compatible reporting cohorts. Each row includes its cohort, rank within that cohort, exact source scope, calculation method, and source link. Never compare ranks across cohorts. |
| get_treatment_outcomes | External-review outcomes for a treatment: how often insurer denials of this treatment/drug/procedure were overturned by independent reviewers (42,749 published CA IMR decisions, 2001–2026). Accepts a category slug (e.g. 'pharmacy') or specific treatment slug (e.g. 'zepbound', 'speech-therapy'). |
| get_condition_outcomes | External-review outcomes for a medical condition: how often insurance denials involving this condition were overturned, plus the most-fought treatments for it. |
| search_outcomes | Search treatments (categories + specific drugs/procedures) and conditions by name. Returns slugs for get_treatment_outcomes / get_condition_outcomes plus headline overturn rates. |
| get_appeal_rights | Deterministically resolve the governing appeal route, missing facts, filing recipient, deadlines, current external-review status, and verified grounds. Distinguishes Original Medicare, Medicare Advantage medical benefits, Part D pharmacy benefits, employer funding/governance, ACA, Medicaid, FEHB, TRICARE, and unknown coverage; unsupported or ambiguous routes fail closed. |
| get_drug_playbook | Drug-specific denial patterns and appeal strategy for the medications plans fight hardest over: GLP-1s (Wegovy, Zepbound, Mounjaro, Ozempic, Saxenda) and IBD biologics (Humira, Skyrizi, Stelara, Entyvio, Remicade, Rinvoq). Returns FDA-approved indications stated conservatively, why plans deny that specific drug, what winning appeals argue, and the step-therapy exception framing — plus the published external-review record for the drug when the corpus has it. Accepts a brand or generic name. |
| get_state_external_review | How a state's external review process works: filing deadline, regulator contact, and key facts. Verified detail currently covers 10 states (CA, TX, FL, NY, PA, IL, OH, GA, NC, MI); other states return the covered list. |