Multi-payer coverage reasoning with cited appeals strategy
Medicare NCDs, 2,500+ LCDs across 12 MAC jurisdictions, 50-state Medicaid, and top-30 commercial payer medical policies — integrated into calibrated-confidence coverage determinations. Where payers disagree, CONTESTED surfaces the conflict. Where a claim is denied, appeals strategy surfaces cited ALJ/QIC/DAB precedent and a narrative skeleton grounded in the strongest overturning cases. Every response is signed and audit-ready.
Coverage-rules reasoning is a multi-payer, multi-jurisdiction, perpetually-contested mess
No vendor sells calibrated-confidence + claim-level grounded reasoning across the full multi-payer reimbursement corpus with cited NCD/LCD/policy/appeals-precedent chains and regulator-acceptable audit trails. The closest analogs (MCG, InterQual) are content + rule-engine licensing products with no per-finding calibration, no CONTESTED-payer surfacing, and no appeals-precedent reasoning.
Five core reasoners, all grounded and signed
Coverage determination
Given payer, service code, diagnosis code, patient context, place of service, and date of service — return covered / covered-with-conditions / not-covered / NOT_DETERMINED. Every response includes cited NCD/LCD/policy chain, required documentation checklist, site-of-service constraints, frequency limits, and prior-auth flag. ECE-calibrated confidence score on every determination.
Multi-payer comparison
Side-by-side coverage matrix across Medicare, Medicaid, and commercial payers for any (service, diagnosis, geography) combination. CONTESTED signal surfaces where payers materially disagree on coverage scope — the agreement ratio, permissive payers, and restrictive payers all returned explicitly. Used for market-access strategy, patient-financial counseling, and forum-shopping in coverage requests.
Appeals strategy with cited precedent
Given a denial and fact pattern, surface cited overturning precedent at the appropriate appeals level (redetermination, QIC, ALJ, DAB), statutory and regulatory grounds, strongest analogous fact patterns, a narrative skeleton, and a calibrated success-likelihood estimate. This is a structured citation frame, not a generated letter — keeping Skippy clear of unauthorized-practice-of-law exposure.
DRG/APC classification
MS-DRG and APC assignment with cited grouper logic. Given principal + secondary ICD-10 diagnoses, principal + additional procedures, discharge date, and grouper version — returns DRG/APC code, description, payment weight, CC/MCC reasoning, and alternative DRGs considered with rejection rationale. 98%+ accuracy target on 500-case test set.
NCCI edit screening
Surface NCCI PTP edits, MUE violations, and modifier-exception reasoning before claim submission. Returns column1/column2 CPT pair edit type, modifier indicator, clinical-exception modifier rules (−59/−25/−91), and recommended action per line. Zero false-negatives on documented edit violations is the target.
Temporal as-of-date-of-service reasoning
Coverage rules are version-pinned to the date of service — mandatory for claim reasoning. Every NCD/LCD/policy finding carries effective-date, retirement-date, and superseded-by tracking. Historical coverage queries return the rule set in force on that date, not today's.
The full reimbursement rules corpus — ingested and versioned
Every participant in the coverage decision chain
When Medicare says a service is not covered but a commercial payer covers it with conditions, Skippy does not average the two into a blended answer. The CONTESTED signal is surfaced explicitly — which payers cover, which don't, the agreement ratio, and the cited policy basis for each position. For appeals firms and patient advocates, this is the most valuable signal: where payers diverge is exactly where coverage arguments exist. For payer medical-policy teams, it is where harmonization decisions need to be made.
CMS mandates electronic prior auth by 2027
CMS-0057-F requires payers to implement electronic prior authorization and to provide specific, actionable denial reasons traceable to versioned clinical criteria. Skippy Reimbursement provides the grounded-reasoning substrate for criteria match — the same substrate powering Skippy Auth for prior authorization. Reimbursement extends that to the full coverage-rules corpus: not just prior-auth criteria, but every NCD/LCD/medical policy that governs whether a service is covered at all. The signed finding_id is the lineage walk entry point that satisfies the CMS specific-reason requirement.
Interested in Skippy Reimbursement?
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