# Source register

Use this register to ground the skills. Verify current deadlines, thresholds, model scope, contractor instructions, and coverage requirements against the notice and current primary authority before giving case-specific guidance.

## Primary Medicare sources

- CMS, [Original Medicare (Fee-for-service) Appeals](https://www.cms.gov/medicare/appeals-grievances/fee-for-service). Current overview of the five appeal levels.
- CMS, [First Level of Appeal: Redetermination by a Medicare Contractor](https://www.cms.gov/medicare/appeals-grievances/fee-for-service/first-level-appeal-redetermination-medicare-contractor). Filing elements and current redetermination guidance.
- CMS, [Additional Documentation Request](https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-education/additional-documentation-request). ADR purpose and contractor context.
- CMS, [Medicare Program Integrity Manual, Publication 100-08](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019033), especially Chapter 3 for medical-record review, amendments, corrections, delayed entries, signatures, and contractor actions.
- CMS, [Medicare Parts A & B Appeals Process, MLN006562](https://www.cms.gov/files/document/mln006562-medicare-parts-b-appeals-process.pdf).
- CMS, [Medicare Advantage appeals and grievances](https://www.cms.gov/medicare/appeals-grievances/managed-care). Part C uses plan reconsideration and a Part C IRE; later OMHA/ALJ, Council, and court review may apply to eligible parties under different rules.
- 42 CFR [405.1018](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-I/section-405.1018) and [405.1028](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-I/section-405.1028), for evidence first offered after QIC reconsideration and good-cause review at OMHA.
- 42 CFR [401.305](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-A/part-401/subpart-D/section-401.305), for current Medicare overpayment reporting and return requirements.
- CMS, [WISeR Model](https://www.cms.gov/priorities/innovation/innovation-models/wiser) and the operational guide linked there. The guide changes during the model; use the current posted version.
- The controlling NCD, LCD, billing article, coding guidance, regulation, manual provision, contractor notice, and claim-specific decision in effect for the relevant service and date.

## Arclight public analysis

- Arclight, [Due Process Denied](https://www.arclightaction.com/insights/due-process-denied). Episode-of-care mapping, claim fragmentation, rationale ledgers, and procedural safeguards.
- Arclight, [Rationale Drift in Medicare Audit Appeals](https://www.arclightaction.com/insights/rationale-drift-medicare-audit-appeals). Comparing denial theories across stages.
- Arclight, [Upstream Denials, Downstream Costs](https://www.arclightaction.com/insights/upstream-denials-downstream-costs). System-cost estimates, evidentiary limits, and the absence of sufficiently granular public outcomes data.
- Arclight, [Do You Need a Lawyer for a Skin Substitute Audit Appeal?](https://www.arclightaction.com/insights/do-you-need-a-lawyer-skin-substitute-audit-appeal). Complexity and escalation considerations.
- Arclight, [A Favorable ALJ Decision in Wound Care](https://www.arclightaction.com/insights/favorable-alj-decision-wound-care-real-world-evidence). Organizing patient timelines, product documentation, clinical evidence, and outcomes evidence.
- Arclight, [When a WISeR ADR Appears Outside the Model's Scope](https://www.arclightaction.com/insights/wiser-adr-outside-model-scope). Scope analysis and the principle: respond on time, preserve the claim, and request the correct disposition.

## Source hierarchy

1. Governing statute and regulation, then applicable CMS coverage and procedural authority with its legal weight, jurisdiction, and effective version identified. Do not flatten statutes, NCDs, LCDs, manuals, and articles into equally binding authority.
2. The claim-specific notice or decision for what the reviewer requested or decided and the immediate operational instructions. A notice does not override controlling law; flag conflicts instead of silently substituting a generic deadline.
3. Contemporaneous medical, billing, product, ordering, and submission records for factual support, kept distinct from legal authority.
4. Published clinical evidence and outcomes material, with relevance and limitations stated.
5. Arclight analysis as an organizing framework, not as controlling authority.

For coverage and coding, use the version applicable to the service date; for procedure, check the version applicable to the appeal event. If an exact service date is identifying, ask the user to verify the applicable policy version in their approved environment and supply that public version or criterion. If browsing is unavailable, state which claims remain unverified and proceed with a provisional framework. Never invent quotations, page citations, or a source verification date.

## Privacy and publication sources

- HHS, [De-identification guidance](https://www.hhs.gov/hipaa/for-professionals/special-topics/de-identification/index.html): Safe Harbor and Expert Determination; a quick scrub checklist is not certification.
- OpenAI, [Plugin guidelines](https://developers.openai.com/plugins/plugin-guidelines): public-directory privacy, standalone value, commerce, and advertising requirements.
- OpenAI, [Submission guidance](https://developers.openai.com/plugins/deploy/submission): packaging, review, and public URL requirements.
- OpenAI, [HIPAA configuration](https://learn.chatgpt.com/docs/hipaa-configuration): product-specific eligibility and configuration responsibilities; it does not approve a public plugin for PHI.

Never treat a summary, a prior case, or Arclight commentary as a substitute for controlling authority or the actual record.