Submission companion sheet

Example conversation

You: Case 2026-0417-A is export-ready — the appeal letter and LOMN passed the claim map and the packet manifest is finalized. Build the submission cover sheet for Anthem.

Agent: Reading case.json and ./packet/packet-manifest-2026-0417-A.json. Calling payer_routing_lookup with payer_name="Anthem", plan_type="commercial", appeal_type="clinical-appeal", expedited=false, service_setting="inpatient". Result: channel: "fax", portal_hint: "Availity provider portal supports Anthem appeals for many plan products; verify against the clinic's routing table." Notes reminded me that Anthem splits pre-service, retrospective, and expedited clinical appeals onto different fax numbers — I need the clinic’s Anthem clinical-appeal standard fax from the payer routing table before I render.

You: Hold on — the patient was just discharged 2026-04-19 and needs inpatient-rehab authorization urgently. The physician has already signed the expedited-justification statement.

Agent: Re-running payer_routing_lookup with expedited=true. Channel still fax, but notes now flag “Anthem publishes a separate expedited-appeals fax from the standard pre-service fax. The expedited physician-justification statement must accompany the cover sheet.” I will route against the customer routing table: Anthem clinical-appeal expedited fax pattern, not the standard pre-service pattern.

Agent: Calling submission_sheet_renderer with case_id="2026-0417-A", the routing decision, the 9 attachments from the manifest, expedited=true, and the rationale. Result: isError: true, missing_required: ["date_of_service"] — case.json has service.dates_of_service but the field is empty because the inpatient stay was recorded only on the claim, not yet copied into the case record.

You: Dates of service are 2026-04-17 to 2026-04-19.

Agent: Patched the case record and re-ran the renderer. Wrote ./packet/cover-sheet-2026-0417-A.md. fields_set includes routing_channel, expedited, expedited_rationale, member_id, payer_reference_number, attachments. Audit-log entry appended: channel = fax, expedited = true, cover-sheet path, MA 72-hour clock does not apply (commercial plan).

You: Separate question — I have a prior-auth to send for a different patient on Humira. Which channel?

Agent: payer_routing_lookup with appeal_type="pa-request". Returning channel: "portal", portal_hint: "CoverMyMeds (specialty-pharmacy PA portal; carries the payer's accepted PA form and manages submit-receive)." Notes: specialty-drug PAs commonly route through CoverMyMeds; if the plan’s own PA portal is preferred, confirm against the clinic’s payer routing table before submission.

Sample output excerpt

The skill produces two artifacts: a routing decision returned by payer_routing_lookup, and the rendered cover sheet written to ./packet/cover-sheet-{case_id}.md. Excerpts from case 2026-0417-A (Anthem inpatient-rehab expedited appeal) after the conversation above.

{
  "channel": "fax",
  "fax_hint": null,
  "portal_hint": "Availity provider portal supports Anthem appeals for many plan products; verify against the clinic's routing table.",
  "mailing_address_hint": null,
  "form_number_hint": null,
  "notes": [
    "Anthem splits pre-service, retrospective, and expedited clinical appeals onto different fax numbers. Load the clinic's payer routing table before submission — do not assume a single 'Anthem appeals fax'.",
    "Expedited: Anthem publishes a separate expedited-appeals fax from the standard pre-service fax. The expedited physician-justification statement must accompany the cover sheet.",
    "Inpatient: attach the complete medical record with the appeal unless already submitted with the denied claim (Anthem explicit)."
  ]
}

Rendered cover sheet (./packet/cover-sheet-2026-0417-A.md):

# Submission cover sheet

_Date of submission: 2026-04-21_

## Routing

- **Channel:** FAX
- **Portal hint:** Availity provider portal supports Anthem appeals for many plan products; verify against the clinic's routing table.
- **Routing notes:**
  - Anthem splits pre-service, retrospective, and expedited clinical appeals onto different fax numbers. Load the clinic's payer routing table before submission — do not assume a single 'Anthem appeals fax'.
  - Expedited: Anthem publishes a separate expedited-appeals fax from the standard pre-service fax. The expedited physician-justification statement must accompany the cover sheet.
  - Inpatient: attach the complete medical record with the appeal unless already submitted with the denied claim (Anthem explicit).

> Routing data in this scaffold is a pattern, not a live fax number or URL.
> Verify against the clinic's payer routing table before submission.
> (Customer routing table: Anthem clinical-appeal expedited fax.)

## Payer

- **Payer:** Anthem Blue Cross Blue Shield
- **Plan:** Anthem PPO
- **Plan type:** commercial

## Appeal framing

- **Appeal type:** clinical-appeal
- **Appeal level:** 1st-internal
- **Pre-service / concurrent / retrospective:** retrospective
- **Expedited:** YES
- **Expedited rationale:** Discharge 2026-04-19; standard 30-day timeline would jeopardise the member's ability to regain maximum function. Inpatient-rehab placement window closes within days of acute-care discharge.

## Member and case identifiers

- **Member name:** Jane D.
- **Member ID:** YRK8827461
- **DOB:** 1968-05-14
- **Claim number:** C-9918274461
- **Authorization number:** AU-2026-0417-A
- **Date(s) of service:** 2026-04-17, 2026-04-19
- **Denial date:** 2026-04-17
- **Payer reference number:** CA-2026-0417-A

## Submitter

- **Name:** Priya N. Shah, MD
- **Phone:** (208) 555-0144
- **Fax:** (208) 555-0145
- **Email:** appeals@mountainridgeortho.example

## Attachments

- **Attachment count:** 9

| # | Label | Category | Pages | Date |
|---|---|---|---|---|
| 1 | Appeal letter | top-letter | 3 | 2026-04-21 |
| 2 | Letter of medical necessity | lomn | 4 | 2026-04-21 |
| 3 | Expedited physician-justification statement | expedited | 1 | 2026-04-20 |
| 4 | MRI lumbar spine 2026-02-03 | imaging | 2 | 2026-02-03 |
| 5 | PT evaluation 2026-03-10 (ODI 56%) | chart | 1 | 2026-03-10 |
| 6 | Inpatient medical record (full) | chart | 42 | 2026-04-17 |
| 7 | NASS 2024 Lumbar Fusion Coverage Criteria | guideline | 6 | 2024-07-15 |
| 8 | Anthem denial letter 2026-04-17 | denial | 3 | 2026-04-17 |
| 9 | Claim-to-source index | appendix | 2 | 2026-04-21 |

When channel='mail' instead of fax, the renderer appends a “Certified mail reminder” block at the bottom of the cover sheet:

## Certified mail reminder

Send this packet by **certified mail, return-receipt requested** (PAF guidance).
The filing date is otherwise not provable, which matters for timely-filing
disputes and for any case where the payer later questions receipt.

Extension tools and validations

The skill registers two deterministic tools. Both are workspace-scoped (./packet/cover-sheet-{case_id}.md is resolved inside the project root; path traversal is rejected). The skill deliberately does not submit anything — fax, portal upload, and certified-mail posting happen outside the agent.

payer_routing_lookup

• Inputs: payer_name (free text, matched against Anthem-family and UHC/Optum regex patterns), plan_type (commercial, medicare-advantage, medicaid, erisa, other), appeal_type (clinical-appeal, claim-reconsideration, nomnc-expedited-determination, pa-request), expedited (boolean), service_setting (inpatient, outpatient, post-service).
• Returns: {channel, fax_hint, portal_hint, mailing_address_hint, form_number_hint, notes[]}. channel is one of fax, portal, mail, or ambiguous.
• Scaffold — not live routing data. The tool returns patterns and reminders, not hardcoded fax numbers or URLs. fax_hint is routinely null; the caller is expected to look up the actual fax number in the clinic’s payer routing table (loaded at pilot time). The notes[] entries describe the behaviour the caller has to honour — for example, “Anthem splits pre-service, retrospective, and expedited clinical appeals onto different fax numbers” or “UHC claim reconsideration is PRA-driven: use the Provider Portal claim-reconsideration form.” NOMNC / DENC service-termination cases always route to the state-assigned BFCC-QIO (KEPRO or Livanta) — the lookup returns channel='ambiguous' with a BFCC-QIO form-number hint, because state-to-QIO assignment comes from the customer routing table. Specialty-drug PAs default to CoverMyMeds with a reminder that the plan’s own PA portal may be preferred.
• isError: the lookup does not error. Unknown payer / combination returns channel='ambiguous' — the caller must resolve ambiguity against the clinic’s routing table before rendering.

submission_sheet_renderer

• Inputs: case_id, the normalized case_record from denial-intake-normalizer, the routing decision from payer_routing_lookup, the ordered attachments[] from the packet manifest, and optional plan_type, submitter, expedited flag + expedited_rationale, pre_vs_post_service, appeal_type, appeal_level.
• What it writes: ./packet/cover-sheet-{case_id}.md — routing block (channel + hints + notes), payer block, appeal-framing block (appeal level, pre/concurrent/retro, expedited flag + rationale), member + case identifiers, submitter contact, ordered attachment table with page counts, and a certified-mail reminder when channel='mail'.
• Returns: {ok, path, fields_set[], missing_required[]}.
• isError: true: when any of the four gating identifiers — member_id, payer_name, appeal_type, date_of_service — is missing. The tool does not write a partial cover sheet; it returns the list of missing fields and leaves the workspace clean.

Validation invariants

• Four identifiers gate rendering. member_id, payer_name, appeal_type, and date_of_service must be non-empty before any file is written.
• Expedited rationale required when expedited=true. The renderer emits an explicit “MISSING — expedited flag requires a physician statement…” placeholder when the flag is set without a rationale; a cover sheet without a matching physician statement will be reclassified to standard by the reviewer, resetting the clock.
• MA 72-hour clock on expedited. payer_routing_lookup cites 42 CFR §422.572(b) in the routing notes whenever plan_type='medicare-advantage' and expedited=true, so the deadline pressure is on the cover sheet itself.
• NOMNC / BFCC-QIO routing uses the service-termination date, not the denial date. The NOMNC branch is expedited-determination, not standard appeal; the BFCC-QIO makes its decision within 72 hours of a complete request, and the filing clock runs from the service-termination date the NOMNC lists — not from a denial-letter date.
• Mailed submissions emit a certified-mail reminder. When channel='mail' the renderer appends a PAF-aligned reminder to send certified-mail, return-receipt; the filing date is otherwise not provable and that defeats timely-filing arguments.
• Scaffold routing is never a substitute for the clinic’s routing table. Every rendered cover sheet carries a block-quote warning that the hints are patterns, not live fax numbers, and that the submitter must verify against the customer routing table before sending.

Getting started

1. Run the preceding skills: denial-intake-normalizer (produces case.json), the relevant drafting skill (appeal-letter-builder, letter-of-medical-necessity-builder, or peer-to-peer-prep), clinical-claim-evidence-mapper (must return export_ready: true), and packet-checklist-and-index-generator (produces the packet manifest).
2. Confirm ./packet/packet-manifest-{case_id}.json exists and its missing_required list is empty. If it is not, return to packet-checklist-and-index-generator — the cover sheet lists attachments from this manifest and refuses to render when the manifest is incomplete.
3. Call payer_routing_lookup with the payer name, plan type, appeal type, expedited flag, and service setting. Read the returned channel and notes[] — they describe the routing behaviour (pre-service vs. retro vs. expedited fax separation on Anthem-family; portal preference on UHC; CoverMyMeds default on specialty-drug PA; BFCC-QIO routing on NOMNC).
4. Confirm the channel against the customer routing table. When channel='ambiguous', stop and resolve by consulting the routing table directly. Override the channel when the clinic’s table contradicts the scaffold — the customer table always wins.
5. Load the clinic’s payer routing table (fax numbers, portal URLs, mailing addresses keyed by payer + plan + appeal type + expedited). The scaffold deliberately does not ship real routing data.
6. Call submission_sheet_renderer with the case record, the routing decision, the manifest attachments, the submitter contact, and (when expedited) the physician rationale statement. Resolve any missing_required fields and re-run.
7. Attach the rendered cover sheet as page 1 of the physical or electronic packet. Fax, upload to the payer portal, or send certified-mail per the routing decision. Append an audit-log entry with the channel, the cover-sheet path, and the expected payer response window.

The skill does not fax, upload, or mail the packet. It produces the routing decision and the cover sheet; the physical submission happens through the clinic’s existing channels.