agentsclimarketplace

Insurance appeal

Skill nathan8823/fairbill/.claude/skills/insurance-appeal

Turn your AI agent into a medical-bill negotiation advocate — an open-source playbook of skills, letters, and verified patient rights. Pay what's fair, nothing more.

Install
npx -y skills add nathan8823/fairbill --skill insurance-appeal

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What its author says it does

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Appeal an insurance denial or underpayment — internal appeal, then external review. Use when the EOB shows denied claims, out-of-network processing, or "not medically necessary" determinations.

SKILL.md

2.7 KB, as published. Nobody here has run it

Insurance appeal

Roughly half of appealed denials get overturned — and almost nobody appeals. The appeal is often worth more than any provider-side negotiation, so run it before conceding the balance is really the user's. Deadlines and legal frame: knowledge/rights-and-laws.md §7.

Steps

  1. Read the EOB + denial letter. Extract: the denial reason code and its plain-English meaning, the deadline to appeal (typically 180 days from denial), and the plan's appeal address/portal. Common denial classes and their attacks:
    • Not medically necessary → treating physician letter is the whole game; request one, and cite the plan's own medical policy for the service (findable on the insurer's site).
    • Out-of-network → was it an emergency, or an OON provider at an in-network facility? That's a No Surprises Act violation, not a valid denial (rights-and-laws.md §1).
    • No prior authorization → whose job was the auth? If the in-network provider failed to obtain it, the plan's own rules usually say the member isn't liable; also ask the provider to write it off for their own error.
    • Coding/clerical → the fix is a corrected claim from the provider, not an appeal; call the provider's billing office first.
  2. Gather the record: medical records for the service (HIPAA request via templates/letters/records-request.md if needed), the physician support letter, the plan document/policy language (ask the employer's HR for the SPD if employer-sponsored).
  3. Write the internal appeal — templates/letters/insurance-appeal.md: member/claim numbers, the determination being appealed, the specific plan language, the clinical facts, the ask ("process at the in-network benefit level" / "cover as medically necessary"), exhibits listed. Send by the plan's stated channel + keep proof. User approves before sending.
  4. Track the clock: plans owe a decision in 30 days (pre-service) / 60 days (post-service) for most plans. Expedited if health is at risk.
  5. External review — internal appeal upheld? File for independent external review within 4 months (federal) or per state rules; the reviewer's decision binds the plan. The denial letter must explain how.
  6. Freeze the provider side meanwhile: tell billing the claim is under appeal and ask for a hold — most will pause rather than collect a balance that may vanish.

Keep looking

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