mcp
Medigami: medical bill error scan, denial decoding, appeal deadlines, hospital price lookup
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Medigami: medical bill error scan, denial decoding, appeal deadlines, hospital price lookup
Server tool list (87)
Raw names from tools/list. Only developers need these.
| scan_bill_for_errors | Scan a medical bill or EOB text for errors: duplicate charges, CPT unbundling, upcoding, facility-fee overcharges. Returns flagged anomalies with estimated dollar impact and a total recovery estimate. PHI WARNING: bill text typically contains PHI (patient name, DOB, MRN, insurer ID). Medigami runs a server-side PHI redactor before any downstream LLM call when scan_bill is invoked from the public SKU, but best practice is to redact client-side before passing the bill through an LLM tool call. For your own bill only — this tool is not for reviewing someone else's claims. WHEN TO USE: User pastes or uploads a medical bill, EOB, itemized statement, hospital charge summary, or similar. The bill text can be raw (OCR output fine) — the scanner parses it. Prefer this over manual line-by-line analysis for any bill above ~$100. WHEN NOT: For a denial appeal (generate_appeal_letter). For pre-... |
| generate_appeal_letter | Generate a legally-grounded insurance appeal letter for a denied claim. Returns the letter as a template with [PATIENT NAME] and [PROVIDER NAME] placeholders (structured-only PHI posture). Includes legal citations, recommended attachments, and appeal-deadline calendar. WHEN TO USE: User has a specific claim denied and wants a drafted appeal letter. Requires insurer, denial_reason (CARC code), cpt_code, diagnosis (ICD-10), and dollar amount. Returns an attested letter with reversal rate, insurer-specific tips, recommended attachments. WHEN NOT: If the user only wants to understand a denial code, use denial_code_explainer first. If they haven't received a formal denial yet, don't draft — clarify status first. For non-CARC disputes (e.g. billing errors pre-adjudication), use scan_bill_for_errors. EXAMPLES: - Draft CO-16 appeal to UHC for office visit: `{"insurer":"UnitedHealthcare","d... |
| optimize_prescription | Find the lowest-cost path for a prescription: generics, biosimilars, GoodRx coupons, manufacturer assistance, 90-day fills, and mail-order vs retail comparison. Returns ranked options with annual savings vs current copay. WHEN TO USE: User asks about prescription cost — lowest-price generic, biosimilar, GoodRx coupon, mail-order, manufacturer assistance, or 90-day fill options. WHEN NOT: For insurance-covered Rx copay questions (use copay_model). For medical necessity appeals of formulary denials (use generate_appeal_letter). EXAMPLES: - Find cheapest path for atorvastatin 20mg: `{"drug_name":"atorvastatin 20mg","current_insurance_cost_30day":45,"is_maintenance_med":true}` |
| analyze_glp1_pathways | Find all access pathways for a GLP-1 drug (Ozempic, Wegovy, Mounjaro, Zepbound) given patient eligibility factors. Ranks pathways by monthly cost, flags prior-authorization rules and step-therapy, and returns the recommended appeal strategy if denial is likely. WHEN TO USE: User specifically asks about GLP-1 drugs (Ozempic, Wegovy, Mounjaro, Zepbound) — coverage, prior-auth strategy, step-therapy alternatives. WHEN NOT: For non-GLP-1 prescriptions (use optimize_prescription). |
| verify_attestation | Verify an Ed25519-signed Medigami MCP response envelope — confirm a medical-bill / appeal / denial / rate answer came from Medigami and hasn't been tampered with. Input: the signed envelope + a public key (PEM) or expected-fingerprint you pinned out-of-band. Returns {valid, reason, tracking_id, timestamp, exp, public_key_fingerprint} so callers can cite the result as FRE 902(14) self-authenticating evidence. Usage: (a) Preferred: supply public_key_pem pinned out-of-band. (b) Otherwise: supply expected_fingerprint (SHA-256 of the pinned key); the envelope's embedded fingerprint is compared against it AND the key is fetched over HTTPS from the envelope's public_key_url (or Medigami's well-known URL) for signature verification. Freshness (exp) and fingerprint equality are both checked. Non-repudiation note: this tool deliberately does NOT silently fall back to the local server's ke... |
| watch_appeal_outcome | Subscribe to an appeal outcome by tracking_id. Blocks up to `timeout_seconds` (default 300). Returns the outcome payload as soon as it's recorded, or {status: 'timeout'} if nothing resolved within the window — caller re-invokes to keep watching. Tracking ids are returned by estimate_appeal_success and other Tier 3 moat tools. WHEN TO USE: Caller wants to subscribe to the outcome of an in-flight appeal by tracking_id. WHEN NOT: One-shot queries — prefer the callbacks via /api/outcomes/record. |
| watch_claim_denial | Subscribe to a claim denial event for a given scan_id. Blocks up to `timeout_seconds`. Returns {status: 'denied', ...} as soon as the payer marks the claim denied in claim_status_history, or {status: 'timeout'} if no denial observed within the window. WHEN TO USE: Caller wants to stream denial events for a set of claims. WHEN NOT: One-shot queries. |
| format_citation | Format an LLM-citable reference to a previously-attested Medigami MCP response. Input: either the full signed envelope that an earlier attested tool returned, OR just a tracking_id. Returns a short citation string, a public verification URL a third party can open to inspect and cryptographically verify the payload, and a long-form attribution block. Use this after any substantive Medigami tool call (scan, estimate, resolve, benchmark) so the user has a verifiable reference to the specific answer and its expiration date. WHEN TO USE: After a substantive tool call, generate a citable string + short URL the LLM can paste into its user-facing response for later verification. WHEN NOT: For non-substantive lookups where citation is unnecessary. EXAMPLES: - Generate a citable URL from a tracking_id: `{"tracking_id":"evt_abc123"}` |
| submit_denial_letter | Submit a medical-claim denial letter to the Medigami Denial Common Crawl (public aggregate dataset). Consent-gated — caller must pass consent=true to attest the submission is voluntary. Server-side PHI scrubber runs before any storage; the public aggregate contains only coded fields (insurer_canonical, denial_reason_code, state, cpt_category, dollars_bin, days_to_resolution_bin). Raw text is never republished. Optional tracking_id closes the outcome loop to a prior Medigami scan / resolve call. WHEN TO USE: User wants to contribute a denial letter to the public Denial Common Crawl (consent-gated). PHI is scrubbed before aggregation. WHEN NOT: Just to explain a denial (denial_code_explainer). To draft a response (generate_appeal_letter). |
| verify_mcp_response | DEPRECATED ALIAS of verify_attestation — kept for backward compatibility with v0.1.7 clients. New code should call verify_attestation directly. WHEN TO USE: Reference lookups: individual code details, verifying a provider registry entry, checking a prior Medigami response's signature, or tracking an outcome. WHEN NOT: For composite workflows use the higher-level tool that calls these internally. |
| format_medigami_citation | DEPRECATED ALIAS of format_citation — kept for backward compatibility with v0.1.7 clients. New code should call format_citation directly. WHEN TO USE: Reference lookups: individual code details, verifying a provider registry entry, checking a prior Medigami response's signature, or tracking an outcome. WHEN NOT: For composite workflows use the higher-level tool that calls these internally. |
| estimate_appeal_success | Probability an appeal will be approved, derived from outcome-labeled data weighted by label provenance (IRO determinations, EOB reversals, physician confirmations). Returns probability + 95% CI + sample_size + expected_days_to_resolution + tracking_id. Report the actual outcome later via POST /api/outcomes/record with the same tracking_id to improve future estimates. WHEN TO USE: User or caller wants probability-of-reversal before spending time on an appeal. Returns probability + confidence interval. WHEN NOT: For picking among multiple appeal strategies (appeal_strategy_success_model). As a stand-alone — usually chain into generate_appeal_letter. EXAMPLES: - Gauge CO-50 appeal odds on Aetna: `{"insurer":"Aetna","denial_reason":"CO-50","cpt_code":"72148","state":"TX","amount":1200}` |
| resolve_denial | End-to-end denial resolution: returns appeal probability + confidence interval + a drafted letter template grounded in aggregate outcome data + plan-context flags (ERISA, restrictive-adjuster state). One call, one tracking_id. No recovery-financing product is offered by this tool. WHEN TO USE: Single-shot composite: user has a specific denial and wants scan + estimate + appeal + citation in one call. WHEN NOT: For nuanced step-by-step workflows, call the individual tools in order. EXAMPLES: - End-to-end CO-197 denial resolution: `{"insurer":"Aetna","denial_reason":"CO-197","cpt_code":"45378","state":"TX","amount":1850}` |
| maximize_recovery | Given a prior scan_id, returns a prioritized action list: anomalies ranked by (expected overcharge x recovery probability), with the next steps to pursue each. Use after scan_bill_for_errors. WHEN TO USE: User has already run scan_bill_for_errors and wants the anomalies ranked by expected dollar recovery. WHEN NOT: As a first call — always scan first. |
| explain_appeal_success | Human-readable rationale for an appeal probability. Returns {probability, tier, recommended_posture, rationale, expected_days_to_resolution, tracking_id} grounded in aggregate outcome rates — not model feature weights. Use this when the caller wants 'why' in plain English alongside the number. WHEN TO USE: Reference lookups: individual code details, verifying a provider registry entry, checking a prior Medigami response's signature, or tracking an outcome. WHEN NOT: For composite workflows use the higher-level tool that calls these internally. |
| negotiate_bill_script | Generate a phone script the user can read when negotiating a medical bill directly with the provider. Combines DP-noised commercial rate benchmarks + the caller's household income + federal charity-care rules (IRS §501(r)) into three negotiation angles: financial assistance, self-pay discount, and itemized-bill coding review. Returns the script + reference-only benchmark range (for the user's own research, not an insurance-consulting recommendation) + charity-care tier. Output is educational only; the user negotiates on their own behalf. Some states (notably NY, FL, CA) regulate public-adjuster activity — the attached disclaimer references this. WHEN TO USE: User wants talking points and a target settlement range to negotiate a medical bill with the provider. Best for self-pay and out-of-network balances. WHEN NOT: For a bill that was denied (generate_appeal_letter — the payer, not ... |
| batch_scan_bills | Scan multiple medical bills in one call. Returns per-bill anomaly lists + total recovery estimate across the batch. Input is a list of {bill_text, provider?, insurer?} items (max 10 per call). Much faster than serial scan_bill_for_errors when handling a bulk upload. WHEN TO USE: User has multiple bills or EOBs to review at once (e.g. a family's bills from one visit, or a year of statements). WHEN NOT: For a single bill (use scan_bill_for_errors). |
| lookup_icd10 | Look up an ICD-10-CM diagnosis code or search by keyword. Input is either an exact code (e.g. 'E11.21') or a free-text description phrase ('type 2 diabetes with nephropathy'). Returns either the matching code + description or up to 20 candidate matches. Use when a clinical note uses non-standard phrasing and the correct code is needed for billing. WHEN TO USE: User asks about a specific ICD-10 diagnosis code or wants RAG-search over ICD-10 for a condition name. WHEN NOT: For the matching CPT codes (cpt_to_icd_mapper). For code validation against a payer (code_validation). EXAMPLES: - Find ICD-10 for hypertension: `{"query":"essential hypertension"}` |
| lookup_cpt | Look up a CPT or HCPCS-J code or search by keyword. Covers the most common outpatient billing codes (E/M, preventive, lab, imaging, procedure, cardiology, therapy, behavioral, vaccine, injectable drugs). Note: CPT is a registered trademark of the American Medical Association; full-dataset commercial use requires an AMA license. This tool provides short descriptors for identification in billing-review workflows. WHEN TO USE: User asks about a specific CPT/HCPCS procedure code or wants to search for codes by procedure description. WHEN NOT: For the expected ICD pairings (icd_to_cpt_mapper or cpt_to_icd_mapper). EXAMPLES: - Find CPT for routine office visit: `{"query":"office visit established patient"}` |
| lookup_npi | Look up a provider in the CMS NPPES National Provider Identifier registry. Accepts a 10-digit NPI number OR a provider name (optionally narrowed by 2-char state). Returns up to 20 matches with entity type, specialty, taxonomy code, address, and status. Source: CMS NPPES public API (free, no key required). WHEN TO USE: User wants to verify a specific provider by NPI number, or find a provider by name + state. WHEN NOT: For provider performance analytics (provider_efficiency_score). EXAMPLES: - Look up a provider by NPI number: `{"npi_number":"1234567893"}` |
| verify_dea_authorization | Validate the format + checksum of a DEA registration number (format: [A-Z][A-Z9][0-9]{7}; public checksum algorithm). Useful as a sanity check on a DEA number you were given (e.g. on a prescription label or a provider's letterhead). Scope note: this tool confirms the number is well-formed — it does NOT verify current registration status or the specific controlled-substance schedule the holder is authorized to prescribe. Authority verification requires a licensed DEA data broker (DEA ARCOS, RxMix). WHEN TO USE: Checking if a provider's DEA registration covers a specific controlled-substance CPT. WHEN NOT: For non-controlled-substance claims. |
| lookup_provider_taxonomy | Look up a NUCC provider taxonomy code (the specialty codes used on HIPAA transactions + NPI registrations) or search by keyword. Returns classification + type + optional specialization. Source: NUCC Health Care Provider Taxonomy Code Set (public; CMS-accepted). WHEN TO USE: Resolving a NUCC provider taxonomy code to its specialty description. WHEN NOT: For finding a provider by specialty in a region (not yet implemented). |
| resolve_codes | [Taxonomy A.1 — baseline response (public data only)] Unified code resolver — free-form query or clinical description → ranked ICD-10-CM, CPT, and HCPCS codes with confidence scores. Use when you need to translate symptoms, procedures, or diagnoses into billable codes without running three separate lookups. WHEN TO USE: User asks about medical codes: what a CPT/ICD/HCPCS code means, whether a code combination is valid, or how to map between them. WHEN NOT: For full bill scans (use scan_bill_for_errors). For appealing a coding-related denial (use generate_appeal_letter). |
| code_conflict_detector | [Taxonomy A.5 — delegates to scan_bill_for_errors] Detect CPT unbundling, mutually exclusive code pairs, and NCCI edit violations in a set of codes. Implemented by the bill scanner's anomaly engine. WHEN TO USE: User asks about medical codes: what a CPT/ICD/HCPCS code means, whether a code combination is valid, or how to map between them. WHEN NOT: For full bill scans (use scan_bill_for_errors). For appealing a coding-related denial (use generate_appeal_letter). |
| fair_price_estimator | [Taxonomy B.8 — delegates to benchmark_payer_rate] Fair-market price distribution for a service: DP-noised percentiles (p10, p25, p50, p75, p90) for the given CPT in a ZIP3 region. WHEN TO USE: User wants to understand what a service typically costs, compare prices across regions/providers, or gauge whether a billed amount is reasonable. WHEN NOT: For a specific bill they have in hand, scan_bill_for_errors is more actionable. For insurance-path estimates, use deductible_impact_calculator or coinsurance_simulator. |
| price_variance_analyzer | [Taxonomy B.9 — baseline response (public data only)] Given a target price and a CPT+region, return how many standard deviations above/below the market the target sits, plus confidence. WHEN TO USE: User wants to understand what a service typically costs, compare prices across regions/providers, or gauge whether a billed amount is reasonable. WHEN NOT: For a specific bill they have in hand, scan_bill_for_errors is more actionable. For insurance-path estimates, use deductible_impact_calculator or coinsurance_simulator. |
| claim_consistency_checker | [Taxonomy C.14 — delegates to scan_bill_for_errors] Detect internal contradictions in a claim: time mismatches, mutually exclusive codes, missing required fields, patient-gender/procedure mismatches. WHEN TO USE: Caller is building or validating a claim payload before submission — format, structure, completeness, alignment. WHEN NOT: For an already-submitted and denied claim, use generate_appeal_letter. For market pricing context, use benchmark_payer_rate. |
| bundling_violation_detector | [Taxonomy C.16 — delegates to scan_bill_for_errors] Detect CPT unbundling (billing components of a procedure separately to inflate the claim). Uses the CMS NCCI edits plus payer-specific bundling rules. WHEN TO USE: Caller is building or validating a claim payload before submission — format, structure, completeness, alignment. WHEN NOT: For an already-submitted and denied claim, use generate_appeal_letter. For market pricing context, use benchmark_payer_rate. |
| appeal_success_predictor | [Taxonomy E.25 — delegates to estimate_appeal_success] Given a denial, predict the probability of a successful appeal. Returns probability with 95% CI, sample size, and recommended appeal-strategy tags. WHEN TO USE: User or caller wants a probabilistic estimate (denial likelihood, appeal success, payment delay, etc.) to decide whether to pursue a path. WHEN NOT: For hard facts (dollar amounts, code definitions, deadlines). Predictions carry confidence bands; call out the uncertainty when you relay the number. |
| generate_appeal_letter_v2 | [Taxonomy F.28 — delegates to generate_appeal_letter] [Taxonomy alias] Generate a state-specific insurance appeal letter with UPL-safe disclaimers for 19 US states. Same impl as generate_appeal_letter. WHEN TO USE: User has a denied claim and wants to appeal, or is preparing arguments / evidence / escalation steps for one. WHEN NOT: For explaining what a denial code means without drafting an appeal, use denial_code_explainer first. For finding a negotiation path on a non-denied bill, use negotiate_bill_script. |
| negotiation_strategy_generator | [Taxonomy F.30 — baseline response (public data only)] Given a bill + patient situation, generate a ranked negotiation strategy: hardship appeal, charity-care application, itemization request, phone scripts. WHEN TO USE: User has a denied claim and wants to appeal, or is preparing arguments / evidence / escalation steps for one. WHEN NOT: For explaining what a denial code means without drafting an appeal, use denial_code_explainer first. For finding a negotiation path on a non-denied bill, use negotiate_bill_script. |
| insurance_response_interpreter | [Taxonomy F.31 — baseline response (public data only)] Parse an insurer's response letter or EOB into structured fields: denial reason codes, appeal rights, deadlines, next-step recommendations. WHEN TO USE: User has a denied claim and wants to appeal, or is preparing arguments / evidence / escalation steps for one. WHEN NOT: For explaining what a denial code means without drafting an appeal, use denial_code_explainer first. For finding a negotiation path on a non-denied bill, use negotiate_bill_script. |
| settlement_optimizer | [Taxonomy F.32 — baseline response (public data only)] For a disputed bill, compute the optimal settlement target price balancing probability of acceptance against amount saved. WHEN TO USE: User has a denied claim and wants to appeal, or is preparing arguments / evidence / escalation steps for one. WHEN NOT: For explaining what a denial code means without drafting an appeal, use denial_code_explainer first. For finding a negotiation path on a non-denied bill, use negotiate_bill_script. |
| patient_cost_forecaster | [Taxonomy H.38 — baseline response (public data only)] Given a patient's plan + predicted care needs, forecast annual out-of-pocket spend across expected claims. WHEN TO USE: User is planning for a medical expense, comparing plan options, looking for financial assistance, or trying to structure a payment plan. WHEN NOT: For billing-error analysis (scan_bill_for_errors) or appeal drafting (generate_appeal_letter). |
| insurance_plan_optimizer | [Taxonomy H.39 — baseline response (public data only)] Given a patient's historical claim patterns, rank available insurance plans by expected annual cost. WHEN TO USE: User is planning for a medical expense, comparing plan options, looking for financial assistance, or trying to structure a payment plan. WHEN NOT: For billing-error analysis (scan_bill_for_errors) or appeal drafting (generate_appeal_letter). |
| cash_vs_insurance_optimizer | [Taxonomy H.41 — baseline response (public data only)] For a given service + patient plan, determine whether cash-pay + charity-care beats insurance billing. WHEN TO USE: User is planning for a medical expense, comparing plan options, looking for financial assistance, or trying to structure a payment plan. WHEN NOT: For billing-error analysis (scan_bill_for_errors) or appeal drafting (generate_appeal_letter). |
| financial_risk_exposure_model | [Taxonomy H.42 — baseline response (public data only)] Quantify a patient's financial exposure to medical-debt risk given current plan, health status, and historical claim volatility. WHEN TO USE: User is planning for a medical expense, comparing plan options, looking for financial assistance, or trying to structure a payment plan. WHEN NOT: For billing-error analysis (scan_bill_for_errors) or appeal drafting (generate_appeal_letter). |
| cpt_to_icd_mapper | [Taxonomy II.21 — baseline response (public data only)] For a given CPT, surface the ICD-10 codes typically paired with it for medical-necessity support. WHEN TO USE: User has a CPT code and wants to know what ICD-10 diagnoses commonly pair with it for medical-necessity support. WHEN NOT: For specific payer policy lookups (code_validation). EXAMPLES: - Common ICDs for 99213: `{"cpt_code":"99213"}` |
| icd_to_cpt_mapper | [Taxonomy II.22 — baseline response (public data only)] For a given ICD-10, surface the CPT codes typically billed for that diagnosis. WHEN TO USE: User has an ICD-10 diagnosis and wants to know what CPTs are commonly billed for it. WHEN NOT: For planning specific services (use benchmark_payer_rate once the CPT is chosen). EXAMPLES: - Common CPTs for essential hypertension: `{"icd10_code":"I10"}` |
| code_bundle_validator | [Taxonomy II.25 — baseline response (public data only)] Check a set of CPT codes against NCCI bundling rules (distinct from modifier-based unbundling). WHEN TO USE: User asks about medical codes: what a CPT/ICD/HCPCS code means, whether a code combination is valid, or how to map between them. WHEN NOT: For full bill scans (use scan_bill_for_errors). For appealing a coding-related denial (use generate_appeal_letter). |
| unbundling_detector | [Taxonomy II.26 — delegates to scan_bill_for_errors] Detect CPT unbundling patterns in a claim. Alias of scan_bill_for_errors. WHEN TO USE: User asks about medical codes: what a CPT/ICD/HCPCS code means, whether a code combination is valid, or how to map between them. WHEN NOT: For full bill scans (use scan_bill_for_errors). For appealing a coding-related denial (use generate_appeal_letter). |
| cash_price_estimator | [Taxonomy III.39 — baseline response (public data only)] Estimate a fair cash price for a service in a given region (no-insurance path). WHEN TO USE: Uninsured/self-pay user wants a fair-market cash price for a service. Returns Medicare national as a floor + commercial-multiple band. WHEN NOT: For insurance-covered scenarios (deductible_impact_calculator + coinsurance_simulator). EXAMPLES: - Cash price for office visit: `{"cpt_code":"99213","zip3":"902"}` |
| zip_based_price_variance | [Taxonomy III.41 — baseline response (public data only)] Report price variance for a CPT across ZIP3 regions with DP noise. WHEN TO USE: User wants to understand what a service typically costs, compare prices across regions/providers, or gauge whether a billed amount is reasonable. WHEN NOT: For a specific bill they have in hand, scan_bill_for_errors is more actionable. For insurance-path estimates, use deductible_impact_calculator or coinsurance_simulator. |
| regional_price_benchmark | [Taxonomy III.43 — baseline response (public data only)] Regional price benchmark for a CPT at state/metro/ZIP3 granularity. WHEN TO USE: User wants to understand what a service typically costs, compare prices across regions/providers, or gauge whether a billed amount is reasonable. WHEN NOT: For a specific bill they have in hand, scan_bill_for_errors is more actionable. For insurance-path estimates, use deductible_impact_calculator or coinsurance_simulator. |
| specialty_price_benchmark | [Taxonomy III.44 — baseline response (public data only)] Price benchmark for a CPT within a specific provider specialty. WHEN TO USE: User wants to understand what a service typically costs, compare prices across regions/providers, or gauge whether a billed amount is reasonable. WHEN NOT: For a specific bill they have in hand, scan_bill_for_errors is more actionable. For insurance-path estimates, use deductible_impact_calculator or coinsurance_simulator. |
| inflation_adjusted_price_model | [Taxonomy III.46 — baseline response (public data only)] Inflation-adjusted price comparison across years for a CPT. WHEN TO USE: User has a historical dollar amount and wants it adjusted for medical-care inflation to a given year. WHEN NOT: For current market prices (benchmark_payer_rate). EXAMPLES: - Adjust $1K 3yr forward at medical CPI: `{"base_amount_usd":1000,"years":3}` |
| deductible_impact_calculator | [Taxonomy III.48 — baseline response (public data only)] Estimate how a planned service will draw against the member's deductible. WHEN TO USE: User wants to know how a specific charge affects their deductible (how much draws down, remaining after, post-deductible exposure). WHEN NOT: For total annual out-of-pocket across a year (healthcare_budget_forecaster). EXAMPLES: - Compute deductible drawdown for $4K charge: `{"charge_usd":4000,"deductible_remaining_usd":1735}` |
| coinsurance_simulator | [Taxonomy III.49 — baseline response (public data only)] Simulate member coinsurance exposure across plan-design variants. WHEN TO USE: User wants to model their coinsurance share of a post-deductible charge. Pass charge_usd and optionally coinsurance_rate. WHEN NOT: For flat-copay services (copay_model). EXAMPLES: - Simulate 20% coinsurance on $1K: `{"charge_usd":1000,"coinsurance_rate":0.2}` |
| copay_model | [Taxonomy III.50 — baseline response (public data only)] Model member copay for a service by plan-design class. WHEN TO USE: User wants the typical copay for a service type (primary / specialist / er). Uses KFF EHBS 2024 averages. WHEN NOT: For patient-specific plan details — copay varies by plan design. EXAMPLES: - Typical specialist copay: `{"service_type":"specialist"}` |
| billing_charge_vs_allowed_delta | [Taxonomy III.51 — baseline response (public data only)] Delta between billed charge and payer-allowed amount for a claim line. WHEN TO USE: User wants to understand what a service typically costs, compare prices across regions/providers, or gauge whether a billed amount is reasonable. WHEN NOT: For a specific bill they have in hand, scan_bill_for_errors is more actionable. For insurance-path estimates, use deductible_impact_calculator or coinsurance_simulator. |
| price_anomaly_detector | [Taxonomy III.52 — baseline response (public data only)] Detect service-line prices statistically anomalous versus market. WHEN TO USE: User wants to understand what a service typically costs, compare prices across regions/providers, or gauge whether a billed amount is reasonable. WHEN NOT: For a specific bill they have in hand, scan_bill_for_errors is more actionable. For insurance-path estimates, use deductible_impact_calculator or coinsurance_simulator. |
| overpriced_service_detector | [Taxonomy III.53 — baseline response (public data only)] Flag services billed materially above market percentile thresholds. WHEN TO USE: User wants to understand what a service typically costs, compare prices across regions/providers, or gauge whether a billed amount is reasonable. WHEN NOT: For a specific bill they have in hand, scan_bill_for_errors is more actionable. For insurance-path estimates, use deductible_impact_calculator or coinsurance_simulator. |
| market_price_distribution_model | [Taxonomy III.55 — baseline response (public data only)] Full DP-noised market price distribution for a CPT+region pair. WHEN TO USE: User wants to understand what a service typically costs, compare prices across regions/providers, or gauge whether a billed amount is reasonable. WHEN NOT: For a specific bill they have in hand, scan_bill_for_errors is more actionable. For insurance-path estimates, use deductible_impact_calculator or coinsurance_simulator. |
| price_outlier_detector | [Taxonomy III.56 — baseline response (public data only)] Detect claim-line outliers relative to a learned market distribution. WHEN TO USE: User wants to understand what a service typically costs, compare prices across regions/providers, or gauge whether a billed amount is reasonable. WHEN NOT: For a specific bill they have in hand, scan_bill_for_errors is more actionable. For insurance-path estimates, use deductible_impact_calculator or coinsurance_simulator. |
| procedure_cost_decomposition | [Taxonomy III.57 — baseline response (public data only)] Decompose the cost of a procedure into component services + facility + professional fees. WHEN TO USE: User wants to understand what a service typically costs, compare prices across regions/providers, or gauge whether a billed amount is reasonable. WHEN NOT: For a specific bill they have in hand, scan_bill_for_errors is more actionable. For insurance-path estimates, use deductible_impact_calculator or coinsurance_simulator. |
| price_recommendation_engine | [Taxonomy III.58 — baseline response (public data only)] Recommend a reasonable price to propose to a provider for a service (self-pay or negotiation). WHEN TO USE: User wants to understand what a service typically costs, compare prices across regions/providers, or gauge whether a billed amount is reasonable. WHEN NOT: For a specific bill they have in hand, scan_bill_for_errors is more actionable. For insurance-path estimates, use deductible_impact_calculator or coinsurance_simulator. |
| claim_duplicate_line_detector | [Taxonomy IV.75 — baseline response (public data only)] Detect duplicated service lines within a single claim. WHEN TO USE: Caller is building or validating a claim payload before submission — format, structure, completeness, alignment. WHEN NOT: For an already-submitted and denied claim, use generate_appeal_letter. For market pricing context, use benchmark_payer_rate. |
| denial_reason_classifier | [Taxonomy VI.106 — baseline response (public data only)] Classify a denial letter or remittance advice into normalized denial-reason categories. WHEN TO USE: User or caller wants a probabilistic estimate (denial likelihood, appeal success, payment delay, etc.) to decide whether to pursue a path. WHEN NOT: For hard facts (dollar amounts, code definitions, deadlines). Predictions carry confidence bands; call out the uncertainty when you relay the number. |
| appeal_argument_generator | [Taxonomy VII.120 — baseline response (public data only)] Generate component arguments for an appeal letter: medical-necessity, contract, policy. WHEN TO USE: User has a denied claim and wants to appeal, or is preparing arguments / evidence / escalation steps for one. WHEN NOT: For explaining what a denial code means without drafting an appeal, use denial_code_explainer first. For finding a negotiation path on a non-denied bill, use negotiate_bill_script. EXAMPLES: - Argument blocks for CO-50 with UHC: `{"denial_code":"CO-50","insurer":"UnitedHealthcare"}` |
| denial_response_builder | [Taxonomy VII.121 — baseline response (public data only)] Build a denial-response package tailored to the denial reason code. WHEN TO USE: User has a denied claim and wants to appeal, or is preparing arguments / evidence / escalation steps for one. WHEN NOT: For explaining what a denial code means without drafting an appeal, use denial_code_explainer first. For finding a negotiation path on a non-denied bill, use negotiate_bill_script. EXAMPLES: - Build response package for CO-197: `{"denial_reason":"CO-197","insurer":"Aetna","cpt_code":"45378","amount":1850}` |
| dispute_case_builder | [Taxonomy VII.123 — baseline response (public data only)] Assemble a complete dispute case file including claim, denial, evidence, and timeline. WHEN TO USE: User has a denied claim and wants to appeal, or is preparing arguments / evidence / escalation steps for one. WHEN NOT: For explaining what a denial code means without drafting an appeal, use denial_code_explainer first. For finding a negotiation path on a non-denied bill, use negotiate_bill_script. |
| evidence_pack_generator | [Taxonomy VII.124 — baseline response (public data only)] Generate an evidence package supporting a claim or appeal (references, studies, policies). WHEN TO USE: User has a denied claim and wants to appeal, or is preparing arguments / evidence / escalation steps for one. WHEN NOT: For explaining what a denial code means without drafting an appeal, use denial_code_explainer first. For finding a negotiation path on a non-denied bill, use negotiate_bill_script. |
| claim_rebuttal_generator | [Taxonomy VII.128 — baseline response (public data only)] Generate a rebuttal to a payer's denial rationale point-by-point. WHEN TO USE: User has a denied claim and wants to appeal, or is preparing arguments / evidence / escalation steps for one. WHEN NOT: For explaining what a denial code means without drafting an appeal, use denial_code_explainer first. For finding a negotiation path on a non-denied bill, use negotiate_bill_script. |
| appeal_escalation_path_finder | [Taxonomy VII.129 — baseline response (public data only)] Find the correct escalation path for a denied claim (internal appeal → external review → DOI). WHEN TO USE: User needs to know the deadlines and agencies for each step of appealing a denial. Pass state (e.g. 'CA') and insurer for state-specific and insurer-specific values. WHEN NOT: Without state/insurer — still works but returns generic federal defaults. Follow up with state for best answer. EXAMPLES: - CA / UnitedHealthcare escalation path: `{"state":"CA","insurer":"UnitedHealthcare"}` |
| payer_specific_appeal_templates | [Taxonomy VII.130 — baseline response (public data only)] Return payer-specific appeal templates known to perform well. WHEN TO USE: User has a denied claim and wants to appeal, or is preparing arguments / evidence / escalation steps for one. WHEN NOT: For explaining what a denial code means without drafting an appeal, use denial_code_explainer first. For finding a negotiation path on a non-denied bill, use negotiate_bill_script. |
| denial_code_explainer | [Taxonomy VII.131 — baseline response (public data only)] Explain a CARC/RARC denial code in plain language with common causes. WHEN TO USE: User asks 'what does CO-16 mean' or similar — any CARC/RARC code. Returns full X12 table entry when available with meaning, category, typical root cause, primary remediation, and reversibility flag. WHEN NOT: For drafting an appeal (generate_appeal_letter). For the full escalation path (appeal_escalation_path_finder). EXAMPLES: - Explain CARC CO-16: `{"code":"CO-16"}` - Explain CARC CO-50 (medical necessity): `{"code":"CO-50"}` |
| claim_reconsideration_builder | [Taxonomy VII.132 — baseline response (public data only)] Build a claim reconsideration request (lighter-weight than a formal appeal). WHEN TO USE: User has a denied claim and wants to appeal, or is preparing arguments / evidence / escalation steps for one. WHEN NOT: For explaining what a denial code means without drafting an appeal, use denial_code_explainer first. For finding a negotiation path on a non-denied bill, use negotiate_bill_script. |
| supporting_document_selector | [Taxonomy VII.135 — baseline response (public data only)] Select optimal supporting documents for an appeal from an available document pool. WHEN TO USE: User is preparing an appeal and needs a ranked list of supporting documents for the denial category. Pass denial_code. WHEN NOT: Without denial_code — still returns generic docs but category-specific ranking is the high-value output. EXAMPLES: - Docs for a CO-50 medical-necessity denial: `{"denial_code":"CO-50"}` |
| out_of_pocket_optimizer | [Taxonomy X.174 — baseline response (public data only)] Optimize out-of-pocket spend across a sequence of planned services. WHEN TO USE: User is planning for a medical expense, comparing plan options, looking for financial assistance, or trying to structure a payment plan. WHEN NOT: For billing-error analysis (scan_bill_for_errors) or appeal drafting (generate_appeal_letter). |
| financial_exposure_model | [Taxonomy X.176 — delegates to financial_risk_exposure_model] Model a member's financial exposure. Alias of financial_risk_exposure_model. WHEN TO USE: User is planning for a medical expense, comparing plan options, looking for financial assistance, or trying to structure a payment plan. WHEN NOT: For billing-error analysis (scan_bill_for_errors) or appeal drafting (generate_appeal_letter). |
| procedure_affordability_ranker | [Taxonomy X.177 — baseline response (public data only)] Rank a set of procedures by affordability for a given member. WHEN TO USE: User is planning for a medical expense, comparing plan options, looking for financial assistance, or trying to structure a payment plan. WHEN NOT: For billing-error analysis (scan_bill_for_errors) or appeal drafting (generate_appeal_letter). |
| treatment_cost_comparator | [Taxonomy X.178 — baseline response (public data only)] Compare expected costs across treatment alternatives for a condition. WHEN TO USE: User is planning for a medical expense, comparing plan options, looking for financial assistance, or trying to structure a payment plan. WHEN NOT: For billing-error analysis (scan_bill_for_errors) or appeal drafting (generate_appeal_letter). |
| bill_shock_predictor | [Taxonomy X.179 — baseline response (public data only)] Predict risk that a planned service will trigger an unexpected large bill. WHEN TO USE: User planning a service and wants to know if it will trigger an unexpected-large-bill situation. Pass expected_charge_usd and optionally cpt_code to get Medicare-ratio context. WHEN NOT: For a bill already received — scan_bill_for_errors first. EXAMPLES: - Check shock risk on $5,000 office visit: `{"expected_charge_usd":5000,"cpt_code":"99213"}` |
| payment_plan_optimizer | [Taxonomy X.180 — baseline response (public data only)] Optimize a payment plan structure for a patient balance. WHEN TO USE: User has a balance and wants to structure a payment plan. Pass balance_usd and months. WHEN NOT: If user may qualify for charity care — run financial_assistance_finder first. EXAMPLES: - 12-month plan for $3K balance: `{"balance_usd":3000,"months":12}` |
| financial_assistance_finder | [Taxonomy X.181 — baseline response (public data only)] Find applicable financial-assistance programs (hospital charity, 340B, state, pharma). WHEN TO USE: User needs help paying a medical bill. Pass household_income_usd and family_size for FPL-based eligibility flags across 6 programs (501(r) charity, Medicaid, PE, manufacturer PAPs, 340B, state pools). WHEN NOT: For insured users with low exposure (use coinsurance_simulator or deductible_impact_calculator). EXAMPLES: - Find assistance for family of 3 at $45K income: `{"household_income_usd":45000,"family_size":3}` |
| patient_cost_explainer | [Taxonomy X.182 — baseline response (public data only)] Explain why a specific charge appears on a bill in plain language. WHEN TO USE: User is planning for a medical expense, comparing plan options, looking for financial assistance, or trying to structure a payment plan. WHEN NOT: For billing-error analysis (scan_bill_for_errors) or appeal drafting (generate_appeal_letter). |
| healthcare_budget_forecaster | [Taxonomy X.183 — baseline response (public data only)] Forecast a household's annual healthcare spend based on plan + utilization. WHEN TO USE: User planning annual healthcare spend, comparing plans, or estimating worst-case exposure. WHEN NOT: For a specific procedure cost (benchmark_payer_rate). EXAMPLES: - Forecast annual spend range: `{}` |
| medical_spending_analyzer | [Taxonomy X.184 — baseline response (public data only)] Analyze a patient's medical spending over a period and surface optimization opportunities. WHEN TO USE: User is planning for a medical expense, comparing plan options, looking for financial assistance, or trying to structure a payment plan. WHEN NOT: For billing-error analysis (scan_bill_for_errors) or appeal drafting (generate_appeal_letter). |
| insurance_value_optimizer | [Taxonomy X.185 — baseline response (public data only)] Recommend insurance-plan selections to maximize value given projected utilization. WHEN TO USE: User is planning for a medical expense, comparing plan options, looking for financial assistance, or trying to structure a payment plan. WHEN NOT: For billing-error analysis (scan_bill_for_errors) or appeal drafting (generate_appeal_letter). |
| patient_financial_risk_score | [Taxonomy X.186 — baseline response (public data only)] Score a patient's financial risk exposure from planned or ongoing care. WHEN TO USE: User is planning for a medical expense, comparing plan options, looking for financial assistance, or trying to structure a payment plan. WHEN NOT: For billing-error analysis (scan_bill_for_errors) or appeal drafting (generate_appeal_letter). |
| decode_denial | Decode a CARC (Claim Adjustment Reason Code) denial code into plain English. Returns meaning, category, whether it's typically reversible on appeal, and appeal guidance. Source: public X12 External Code List + CMS/ERISA public rules. Free, no auth. WHEN TO USE: Reference lookups: individual code details, verifying a provider registry entry, checking a prior Medigami response's signature, or tracking an outcome. WHEN NOT: For composite workflows use the higher-level tool that calls these internally. |
| get_appeal_deadline | External-review filing deadline for a state + the date of the FINAL adverse determination. Returns the deadline date, the statutory window label + citation, and whether the exact state-specific window still needs verification (most states carry a conservative NAIC-model 4-month floor unless statute-confirmed, e.g. CA/NY). Free, no auth. WHEN TO USE: Reference lookups: individual code details, verifying a provider registry entry, checking a prior Medigami response's signature, or tracking an outcome. WHEN NOT: For composite workflows use the higher-level tool that calls these internally. |
| get_venue | Where and how to file an external review for a given state — the venue name, filing channel (portal/mail/fax), portal URL, and whether expedited review is available. Free, no auth. WHEN TO USE: Reference lookups: individual code details, verifying a provider registry entry, checking a prior Medigami response's signature, or tracking an outcome. WHEN NOT: For composite workflows use the higher-level tool that calls these internally. |
| medigami_odds | Historical external-review overturn rate published by the state regulator for the insurer you name, in a regulated venue (CA/NY/MD/NJ/MI/OH/NC). Returns one insurer's own rate — not a comparison or ranking against other insurers. Public regulator data, k-anonymity floored, not legal advice. WHEN TO USE: Reference lookups: individual code details, verifying a provider registry entry, checking a prior Medigami response's signature, or tracking an outcome. WHEN NOT: For composite workflows use the higher-level tool that calls these internally. |
| medigami_roast | Compare a billed charge against a hospital's own MRF-published negotiated rate for a CPT code; returns the markup multiple. Public regulator data, k-anonymity floored, not legal advice. WHEN TO USE: Reference lookups: individual code details, verifying a provider registry entry, checking a prior Medigami response's signature, or tracking an outcome. WHEN NOT: For composite workflows use the higher-level tool that calls these internally. |
| medigami_deadline | Federal appeal-deadline window (ERISA §503 internal-appeal / ACA §2719 external-review / NSA IDR) for a plan type. Public regulator data, k-anonymity floored, not legal advice. WHEN TO USE: Reference lookups: individual code details, verifying a provider registry entry, checking a prior Medigami response's signature, or tracking an outcome. WHEN NOT: For composite workflows use the higher-level tool that calls these internally. |
| medigami_rate | A hospital's own MRF-published negotiated rate for a CPT code (no billed-amount comparison — use medigami_roast for that). Public regulator data, k-anonymity floored, not legal advice. WHEN TO USE: Reference lookups: individual code details, verifying a provider registry entry, checking a prior Medigami response's signature, or tracking an outcome. WHEN NOT: For composite workflows use the higher-level tool that calls these internally. |