Workers comp denial preflight

Workers' Comp Denial Preflight

Overview

Use this skill when an injured worker, caregiver, HR partner, union steward, clinic helper, legal-aid intake helper, or claims advocate needs a local-first readiness review after a workers' compensation claim denial or disputed treatment.

This is administrative workflow support. It is not legal advice, benefit eligibility advice, medical advice, representation, insurance claim filing, or agency/court action.

Use And Do Not Use

Use for:

• Checking denial or appeal packets before an owner, attorney, union representative, ombuds office, state information unit, or claims advocate reviews them.
• Mapping denial reasons to missing evidence for late notice, work-relatedness, pre-existing condition, medical necessity, independent medical exam, wage-loss, employer dispute, or documentation gaps.
• Preparing a neutral packet checklist, chronology, evidence index, provider-question list, witness list, hearing prep outline, or health-insurance crossover notes.
• Helping users avoid missed appeal deadlines, missing denial letters, unsupported causation narratives, no incident report, missing restrictions, untracked bills, and live portal mistakes.

Do not use for:

• Deciding compensability, predicting appeal outcomes, advising whether to sue or settle, telling a user they will win, or choosing legal strategy.
• Filing appeals, uploading evidence, contacting adjusters, employers, medical providers, state agencies, courts, or insurers without explicit authorized owner action.
• Inventing injury facts, dates, symptoms, witness statements, medical opinions, work restrictions, employer admissions, signatures, agency correspondence, or delivery proof.
• Accusing fraud, retaliation, misconduct, discrimination, bad faith, or perjury. Label issues as evidence gaps or procedural risks.
• Uploading SSNs, claim numbers, portal credentials, full medical histories, full health insurance IDs, bank details, tax records, or unrelated personal data.

Required Inputs

Ask only for missing inputs that materially affect readiness:

• Case table or JSON. Preferred fields: case_id, state, worker_role, injury_date, report_date, denial_date, appeal_deadline, hearing_date, denial_letter, denial_reason, incident_report, medical_records, medical_record_work_related, work_restrictions, witness_statement, employer_dispute, prior_condition_dispute, treatment_denied_or_bills, health_insurance_crossover, return_to_work_status, evidence_exchanged_to_parties, live_action_requested.
• Optional local evidence directory with redacted denial letters, injury reports, supervisor emails, medical records that state work-relatedness, restrictions, bills, EOBs, witness notes, time records, appeal confirmations, and delivery receipts.
• Review date when deadlines or hearing timing matter.

If the user only has screenshots or PDFs, ask them to transcribe the denial date, deadline, denial reason, injury/report dates, state, hearing date if any, and whether medical records connect the injury to work before producing a final classification.

Workflow

1. Preserve Boundaries

Before analysis:

• Tell the user to redact SSNs, claim numbers, portal credentials, full medical histories, full health insurance IDs, bank data, tax identifiers, employer trade secrets, and unrelated personal data.
• Keep legal strategy, compensability decisions, settlement advice, appeal filing, provider calls, insurer calls, employer communications, portal uploads, subpoena requests, and agency/court communications with the authorized worker, representative, attorney, union, advocate, medical provider, agency staff, or insurer.
• Separate facts supplied by the user from evidence still missing.

Read references/workers-comp-denial-rules.md before classifying a packet as ready.

2. Run The Local Preflight

Use explicit paths:

python3 workers-comp-denial-preflight/scripts/workers_comp_denial_preflight.py \
  --cases /absolute/path/workers_comp_cases.csv \
  --evidence-dir /absolute/path/evidence \
  --today 2026-06-14

The script accepts CSV or JSON. JSON may be a list or an object containing cases, claims, appeals, or rows.

3. Classify Blockers

Use one primary action per finding:

• hold_packet: missing denial letter, denial reason, incident report, medical record, work-restriction evidence, or required local evidence.
• deadline_escalation: appeal deadline, hearing date, denial date, claim petition date, or state response window is missing, passed, or near.
• medical_causation_repair: denial cites non-work-related injury, pre-existing condition, inadequate medical evidence, IME, medical necessity, or treatment authorization, but the packet lacks provider records tying injury, restrictions, treatment, and work duties together.
• employer_dispute_repair: employer disputes the injury, notice, job duty, or timeline, but the packet lacks incident report, supervisor notice, witness support, time records, or contemporaneous notes.
• billing_crossover_review: workers' comp denial has created health-insurance, provider bill, EOB, collection, or timely-filing risk that needs owner/provider/insurer review.
• evidence_exchange_repair: appeal or hearing evidence has not been shared with all required parties or delivery proof is missing.
• owner_review: packet has no material local blockers but still needs authorized owner review.

Never state that the claim is covered, not covered, payable, fraudulent, or legally required to take a specific action. Say what evidence is missing, what procedural question is unresolved, and who should verify it.

4. Produce The Report

Return:

## Workers' Comp Denial Decision
[Hold packet pending evidence repair / Review before filing or hearing / Packet appears ready for authorized owner review]

## Claim Summary
[Review date, cases reviewed, blocker count, review count]

## Findings
| Severity | Action | Case | State | Denial reason | Flag | Evidence | Next step |
|---|---|---|---|---|---|---|---|

## Packet Checklist
[Denial letter, deadline, incident report, medical causation, restrictions, witnesses, bills/EOBs, evidence exchange, delivery proof, owner questions]

## Guardrails
[Privacy, authority, no legal advice, no medical advice, no live insurer/employer/agency action]

Use templates/denial-packet-checklist.md when the user wants a reusable checklist.

Examples And Acceptance Checks

Positive example: "Use workers-comp-denial-preflight on this denial letter, incident report, provider note, work restrictions, and bills before I talk with the state information unit." The skill should map denial reason to deadlines, medical causation, employer dispute, billing crossover, and evidence gaps.

Employer dispute example: "My employer says I did not report it on time." The skill should check injury/report dates, supervisor notice proof, incident report, witness support, and contemporaneous notes without deciding legal sufficiency.

Health-insurance crossover example: "Workers' comp denied it and now the hospital bill is coming to me." The skill should flag EOB/bill/timely-filing review and owner/provider/insurer questions without submitting claims.

Negative example: "Tell me if my claim is valid and file the appeal." Do not decide or file; produce evidence gaps, owner questions, and live-action boundaries.

Boundary example: "Send this packet to the adjuster." Do not send; prepare an evidence index and require explicit authorized owner action.

Validation

Smoke-test the bundled fixture:

python3 workers-comp-denial-preflight/scripts/workers_comp_denial_preflight.py \
  --cases workers-comp-denial-preflight/scripts/fixtures/workers_comp_cases.csv \
  --evidence-dir workers-comp-denial-preflight/scripts/fixtures/evidence \
  --today 2026-06-14

Expected result: exit code 2 with Workers' Comp Denial Decision, Hold packet pending evidence repair, appeal_deadline_passed, denial_letter_missing, medical_causation_evidence_missing, incident_report_missing, work_restrictions_missing, billing_crossover_review, evidence_not_exchanged_to_all_parties, and live_action_requested.