# Submission companion sheet

> Produce the routing cover sheet for submitting a denial-appeal, claim-reconsideration, or prior-authorization packet to a US payer. Encodes channel selection (fax vs. portal vs. mail), expedited-flag handling, member and claim identifiers, attachment count, and certified-mail reminders. The routing-lookup is scaffolded as patterns (Anthem pre-service vs. retro vs. expedited fax separation; UHC PRA-driven claim-reconsideration routing; CoverMyMeds for PA; payer portals) rather than hardcoded fax numbers — the clinic's routing table is injected at pilot time. Pairs with packet-checklist-and-index-generator (which produces the attachment manifest this cover sheet lists).



Tags: Healthcare, Prior Authorization, Denial Appeals, Submission


## Example Prompts

- Make me the fax cover sheet for this expedited clinical appeal to Anthem
- Which channel should I use for a UHC post-service claim reconsideration?
- Render the submission cover sheet and tell me what identifiers are still missing
- What routing pattern applies to an MA Level 1 expedited reconsideration?

URL: https://rakenne.app/skills/submission-companion-sheet/index.md

Try this skill: https://rakenne.app/a/?skill=submission-companion-sheet



## Overview

Produce the routing cover sheet for submitting a denial-appeal, claim-reconsideration, or prior-authorization packet to a US payer. Encodes channel selection (fax vs. portal vs. mail), expedited-flag handling, member and claim identifiers, attachment count, and certified-mail reminders. The routing-lookup is scaffolded as patterns (Anthem pre-service vs. retro vs. expedited fax separation; UHC PRA-driven claim-reconsideration routing; CoverMyMeds for PA; payer portals) rather than hardcoded fax numbers — the clinic's routing table is injected at pilot time. Pairs with packet-checklist-and-index-generator (which produces the attachment manifest this cover sheet lists).

## What it covers

- **Channel selection.** `fax`, `portal`, `mail`, or `ambiguous` based on payer family, plan type, appeal type, expedited flag, and service setting — Anthem-family splits pre-service / retro / expedited fax; UHC prefers portal for post-service claim reconsiderations; specialty-drug PAs default to CoverMyMeds.
- **Expedited routing.** Surfaces a distinct expedited-fax / expedited-portal reminder and refuses to render expedited without a physician rationale statement.
- **MA 72-hour clock reminder.** When `plan_type='medicare-advantage'` and `expedited=true`, cites 42 CFR §422.572(b) so the clock that starts on payer receipt is explicit on the cover sheet.
- **Certified-mail reminder.** Mailed submissions carry a PAF-aligned certified-mail, return-receipt reminder so the filing date is provable for timely-filing disputes.
- **Member, claim, auth, and payer-reference identifiers.** Gated — the cover sheet refuses to render without `member_id`, `payer_name`, `appeal_type`, and `date_of_service`.
- **Attachment listing.** Ordered attachment table (label, category, pages, date) pulled from the packet manifest so the submitter can cross-check the physical packet page count.

## 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.

---

```json
{
  "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`):

```markdown
# 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:_

```markdown
## 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.
```

<!-- /excerpt -->

## 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.



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