skills/rationale-drift-review/SKILL.md

---
name: rationale-drift-review
description: Compare abstracted or de-identified Medicare decisions to prepare for the next review stage by detecting changed, added, abandoned, fragmented, or inconsistently applied denial rationales. Use when the user has two or more reviewer decisions, multiple related claims, or says the reason for denial keeps changing. Do not use for a standalone evidence map or to claim procedural invalidity without authority.
---

# Rationale Drift and Claim Fragmentation Review

Create a precise comparison of what each reviewer decided, what evidence each considered, and how the issues changed. Describe drift before arguing its significance.

## Shared operating rules

Read and apply [public-workflow.md](../../references/public-workflow.md) for proportionate answers, de-identified inputs, source verification, and user-requested support. Carry these rules across skill transitions; do not repeat the opening notice.

## Workflow

1. Inventory every supplied notice, decision, submission, and claim line by stage and date.
2. Identify the governing program before drawing procedural conclusions. For Medicare Advantage, recognize plan reconsideration and Part C IRE stages and that later OMHA/ALJ, Council, and court review may apply to eligible parties. Do not reuse Original Medicare forms, contractors, deadlines, or evidence rules.
3. Read [references/rationale-ledger.md](references/rationale-ledger.md).
4. Extract each rationale as a discrete proposition, preserving the decision's meaning.
5. Link the proposition to the affected claim lines, dates, codes, record evidence, policy citation, and disposition.
6. Compare adjacent stages and label each rationale `continued`, `narrowed`, `expanded`, `new`, `not repeated`, `expressly withdrawn or resolved`, `contradictory`, or `unclear`. A rationale omitted from a later decision is not necessarily abandoned, waived, or resolved.
7. Distinguish true rationale drift from a more detailed explanation of the same issue, a new-record response, or differences between claim populations.
8. Identify prejudice or workload effects concretely: inability to respond earlier, new evidence needed, inconsistent outcomes, duplicate proof, or claim fragmentation.
9. Produce both a neutral ledger and a proposed procedural argument. Do not assert that drift automatically voids a decision.

## Required output

### Decision inventory

| Stage/date | Reviewer | Claims/services | Outcome | Evidence identified as reviewed |
|---|---|---|---|---|

### Rationale ledger

| Issue ID | Stage 1 | Stage 2 | Later stage | Change label | Claims affected | Record/policy basis |
|---|---|---|---|---|---|---|

### Claim-fragmentation map

Show related claims that received different rationales or outcomes. State whether the differences can be explained by claim facts, records, procedural posture, or reviewer variation.

### Materiality assessment

For each change, explain whether it altered the evidence needed, the governing rule, the claim population, or the relief requested.

### Proposed response points

Separate:

- direct merits responses;
- requests for clarification or consistent treatment;
- procedural fairness concerns;
- preservation points for later review; and
- issues requiring counsel.

## Guardrails

- Do not call every wording difference rationale drift.
- Do not claim a due-process violation, waiver, estoppel, or invalid decision as a legal conclusion without governing authority and counsel review.
- Do not assume all claims in an episode are identical.
- Do not use a later favorable decision as binding precedent for unrelated claims.
- Preserve adverse rationales in the ledger; do not omit them to strengthen the narrative.