Provider Denial Workup — Reasoning Skill

Overview

Guide the agent through structured analysis of payer claim denials: classify the denial category, determine the appropriate appeal posture, and draft a payer-ready appeal letter. This skill encodes CARC/RARC interpretation, appeal pathway logic, and letter-drafting standards for revenue cycle staff.

When to Use

• A claim has been denied and the user wants to understand why and what to do next
• The user provides a remittance advice (835 ERA) showing a denial and asks for next steps
• The user needs a draft appeal letter for a specific denial reason
• The user wants to classify a denial as actionable (appealable) vs. non-actionable