Claims Billing Rules — Reasoning Skill

Overview

Guide the agent through CMS billing rules, NCCI edit logic, and fraud/waste/abuse (FWA) detection patterns. This skill encodes regulatory knowledge and decision frameworks for claims analysis, audit, and compliance review.

Usage

• Invoke when reasoning about CMS billing compliance or modifier usage
• Use for NCCI edit logic, global surgery period rules, or FWA detection patterns
• Activate for claims audit methodology or coding error vs fraud distinction

Core Concepts

Response Format