Per-case workflow
Nine skills. One case. One packet out the door.
Each skill owns one step of the denial-appeal and prior-auth workflow. They share a single `case.json`, a single evidence store, and a single per-case audit log. Start a case with a denial letter and a few chart documents — end with a reviewer-ready packet.
Denial intake normalizer
Parse denial letters, EOBs, Medicare Advantage IDNs, NOMNC/DENC, and payer appeal forms into a structured case.json. Classifies the denial reason, routes the appeal type, and computes the appeal deadline.
- MA IDN, NOMNC/DENC, Anthem and UHC form parsing
- Deadline countdown with expedited routing
- plan_type capture (commercial / MA / Medicaid / ERISA)
Clinical-claim evidence mapper
Extract every clinical claim from the drafted letters and map each one back to a chart excerpt with document, page, and span. Blocks export when any claim is uncited.
- Extract / cite / uncite / list / check / render index
- Orphan detection against the current draft
- Claim-to-source index attached to the packet
Letter of medical necessity builder
Structured LOMN with patient IDs, ICD-10 validation, prior-therapy history (name, duration, outcome, discontinuation reason), 22 disease-specific scoring instruments, and mandatory-section completeness checks.
- Genentech and Novartis field models
- 22 disease-score instruments (UAS7, PASI, DAS28, ODI, NDI, ECOG, PHQ-9, …)
- LOMN completeness check before export
Appeal letter builder
Denial-reason-specific rebuttal letter tied to the cited policy language and clinical evidence. Covers step therapy, experimental/investigational, medical necessity, lack of PA, and out-of-network denial categories.
- Denial-reason rebuttal checker
- Preferred-therapy argument generator for step-therapy
- Contradiction checker (10 mismatch rules)
MSK specialty overlay (lomn-msk)
First pilot specialty overlay on top of the LOMN builder. Enforces conservative-care documentation, pain/function score trend analysis, and imaging-to-symptom concordance. Designed against the payer-policy split on spine procedures.
- Conservative care validator (PT, NSAIDs, ESI, duration)
- ODI / NDI / VAS score-trend check
- MRI/CT concordance with reported symptoms
Packet checklist & index
Required and optional attachment list driven by denial category, specialty, and plan type. Produces the packet manifest and the claim-to-source index bound to the evidence map.
- PAF-style packet composition by denial type
- DMEPOS overlay (face-to-face encounter, detailed written order)
- MA IRE / ERISA claim-file / Medicaid fair-hearing branches
Submission companion sheet
Routing cover sheet — fax vs. portal vs. mail, expedited flag, auth number, dates of service, attachment list. Plan-type aware: commercial, MA IRE / Part D IRE, ERISA voluntary external review, Medicaid MCO vs. state fair-hearing.
- Pattern-only routing — customer fax table injected at pilot onboarding
- Expedited vs. standard timeline handling
- on_behalf_of_member rendering for member appeals
Peer-to-peer prep
One-page brief for scheduled peer-to-peer calls: case summary, denial reason, key clinical facts, prior-therapy timeline, likely reviewer questions with suggested answers.
- Built from the shared case.json — no re-entry
- Likely-questions generator per denial category
- Completeness check before the call
PHI redaction
Pre-publication PHI scrubber for anonymized case studies. Scans, applies DAY+n date anchoring, and audits the output against a HIPAA Safe Harbor checklist. The gate you want before posting a teardown.
- Safe Harbor identifier coverage
- DAY+n relative date preservation
- Audit-check blocks accidental PHI leaks
How it compares
Why specialty clinics and RCM firms choose Rakenne
Templates in Word break on payer-specific criteria. Generic chatbots hallucinate clinical content no reviewer will trust. Rakenne runs the packet like an operational workflow — evidence-first, completeness-gated, submission-ready.
See it in action
The evidence map blocks export until every claim is cited
The single most effective trust control for this buyer is refusing to export a letter that contains an unsupported clinical claim. It catches hallucinations and it catches rushed drafting.
A step-therapy appeal, walked through the gate
In this example, the agent drafts a step-therapy appeal, maps each clinical claim to the chart, detects two uncited claims, pulls them from the record, and re-validates before export.
clinical_claim_extract_candidates on the draft…Found 11 clinical claims. 9 cited. 2 uncited:
- “Patient failed methotrexate 20 mg weekly for 14 weeks with no improvement in DAS28.”
- “Contraindication to sulfasalazine due to documented G6PD deficiency.”
Proposed citations:
- Claim 1 →
chart/rheum-2026-02-14.pdfp. 2, span “MTX 20 mg QW × 14 wk, DAS28 unchanged 5.1 → 5.0” - Claim 2 →
labs/cbc-panel-2025-11-03.pdfp. 1, span “G6PD activity 2.1 U/gHb (low)”
clinical_claim_check_draft again…appeal_completeness_check + contradiction_checker…Denial and appeal coverage
Every denial type, every appeal pathway
The skill set covers the denial categories and appeal pathways that account for the bulk of specialty-clinic and RCM workload. Specialty overlays are added as pilots bring real volume.
Denial categories
- Not medically necessary
- Experimental / investigational
- Step therapy / formulary
- Lack of prior authorization
- Out-of-network
- Timely filing
- Post-service reimbursement dispute
- Service termination (NOMNC)
Appeal pathways
- Clinical (medical-necessity) appeal
- Post-service claim reconsideration
- Medicare Advantage Level-2 IRE
- Part D expedited redetermination
- ERISA external review (IRO)
- Medicaid fair hearing (state + MCO)
- BFCC-QIO expedited determination (NOMNC)
- DMEPOS prior authorization
First pilot specialties
- Musculoskeletal / spine / pain (lomn-msk shipped)
- Oncology (next)
- Rheumatology (next)
- GI biologics
- Behavioral health
- DMEPOS / sleep / respiratory
Reference corpus
- CMS Integrated Denial Notice (MA)
- CMS NOMNC / DENC
- CMS DMEPOS PA process
- Anthem Provider Clinical Appeal Request
- UnitedHealthcare claim reconsideration
- Patient Advocate Foundation appeal guide
- Genentech LOMN & appeal templates
- Novartis RHAPSIDO PA + appeals kit
- HL7 Da Vinci PAS / DTR / CRD
Go deeper
The nine skills in detail
Each skill page includes the canonical conversation, sample output, tool reference, and getting-started instructions. Published and kept in sync with the shipped skills.
Intake & evidence
Drafting
- Letter of medical necessity builder 10 min
- MSK specialty overlay 8 min
- Appeal letter builder 10 min
- Peer-to-peer prep 6 min
Packaging & submission
FAQ
Common questions from RCM and utilization-management teams
redaction-tool skill gates any anonymized case study before publication. A BAA is available to design-partner pilots.lomn-msk) — spine, pain, orthopedics. Oncology and rheumatology are the likely next two, chosen after pilot volume tells us where the denial workload is heaviest. Pilots drive the specialty roster, not a marketing roadmap.Five design-partner pilot slots. One specialty focus. Paid.
We are opening five paid design-partner pilots across independent specialty clinics, RCM firms serving specialty practices, and boutique denial-management services. Pilots run 30–45 days on live backlog cases with founder-led onboarding. If you're doing 20+ appeals a week and you want a real operational tool instead of another template pack — let's talk.