Arclight Readiness Navigator

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---
name: appeal-pathway-outlook
description: Give an evidence-grounded readiness outlook for a de-identified Original Medicare fee-for-service audit or appeal across redetermination, QIC reconsideration, OMHA/ALJ, Appeals Council, and possible court review. Use when the user asks how far a case may need to go, what to prepare at each level, reversal likelihood, or whether specialist/counsel involvement is warranted. Do not invent precise odds or apply aggregate statistics without compatible denominators.
---

# Medicare Appeal Pathway Outlook

Help the user plan resources and evidence across appeal levels without false precision. An outlook is not a prediction or guarantee.

## Scope

This skill addresses Original Medicare fee-for-service claims. Do not apply its pathway to Medicare Advantage, Part D, beneficiary fast appeals, or another program without switching to the governing process.

## 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. Confirm the current stage, review program, claim population, amount at issue, recoupment posture, jurisdiction, and the latest stated rationales.
2. Read [references/outlook-method.md](references/outlook-method.md).
3. Verify the current appeal sequence, deadlines, amount-in-controversy thresholds, and filing rules against the notice and current CMS sources.
4. Assess case factors separately: record support, policy fit, claim reconciliation, rationale stability, procedural posture, credibility/testimony needs, and external evidence.
5. Identify which factors can improve at the next level and which are fixed historical constraints.
6. Use numeric outcome estimates only when a source has a disclosed denominator, period, population, decision unit, and relevance to this case. Show the arithmetic and transferability limits.
7. If compatible statistics are unavailable, use `low`, `guarded`, `meaningful but uncertain`, or `stronger` qualitative bands with reasons and confidence. Do not disguise a score as a probability.
8. Produce a stage plan, budget/workload considerations, and escalation points.

## Required output

### Bottom line

State the likely planning horizon: resolve at current stage, prepare simultaneously for QIC, plan for OMHA/ALJ, or seek immediate specialist/counsel review. Phrase this as a resource-planning judgment, not a forecast.

### Case-factor assessment

| Factor | Current signal | Evidence | Can improve? | Effect on outlook | Confidence |
|---|---|---|---|---|---|

### Stage-by-stage outlook

| Level | Decision maker | What usually changes | Case-specific opportunity | Main risk | Preparation now |
|---|---|---|---|---|---|

Use the formal names: MAC redetermination; QIC reconsideration; OMHA/ALJ; Medicare Appeals Council; federal district court.

### Quantitative evidence, if any

For each statistic show:

- numerator and denominator;
- period;
- population and decision unit;
- source;
- whether it is conditional on reaching that stage;
- whether it measures full or partial favorability;
- arithmetic; and
- why it is or is not transferable to this case.

### Workload and escalation

Identify the record volume, claim count, declarations, expert or clinical evidence, hearing preparation, representative requirements, counsel issues, and decision points that drive cost.

### Next decision gate

Give the next action, evidence needed, responsible owner, and date by which the go/no-go decision should be made.

When specialist or counsel review is warranted, say why. Legal-risk triggers call for qualified healthcare counsel; operational complexity may call for a Medicare appeals specialist. Apply the shared support rule for requested contact information; do not use case weakness as a publisher referral trigger.

## Guardrails

- Never say that “most cases” reach QIC or ALJ unless a compatible source supports that statement.
- Do not use Arclight's experience as a population estimate. Label it as nonrandom professional experience only if the user supplies an auditable denominator and authorizes its use.
- Do not combine stage-specific rates as though they were independent. State whether rates are conditional or cumulative.
- Do not treat lack of granular public contractor data as zero success.
- Do not promise reversal, recoupment protection, or a hearing date.
- Recommend counsel based on legal complexity and risk, not merely because the case is unfavorable.

Referenced files: 1

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---
name: focused-appeal-response
description: Build or revise a focused reviewer-facing response framework from a de-identified Medicare readiness map for an ADR, audit finding, prepayment denial, redetermination, QIC reconsideration, or OMHA/ALJ issue. Use after the notice, record evidence, and current authority are mapped. Produces a working external draft and attachment plan without dumping the internal vulnerability memo into the submission. Do not use to fabricate facts, hide requested material information, or guarantee reversal.
---

# Focused Appeal Response

Write a truthful, issue-led external submission. Use the decision's actual rationale, not a generic medical-necessity argument.

## Scope

This skill is for Original Medicare fee-for-service review and appeals. If the notice concerns Medicare Advantage (Part C), Part D, a beneficiary fast appeal, Medicaid, or another program, stop and route the work from that program's governing notice and current authority. Medicare Advantage uses plan reconsideration and a Part C Independent Review Entity rather than MAC redetermination and QIC reconsideration; later ALJ, Council, and court review may apply to eligible parties, but forms, deadlines, party status, and contracted-provider rules differ. Never reuse the fee-for-service pathway by analogy.

## Entry criteria

Before drafting, require:

- a de-identified notice or accurate statement of the current issues;
- appeal/review level and deadline;
- claim or episode scope;
- record citations for material factual statements;
- the controlling policy or a plan to verify it; and
- provider validation for clinical facts supplied by nonclinical staff.

If these are incomplete, produce a drafting plan and missing-information list instead of a polished final letter.

## 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. Read [references/external-drafting-protocol.md](references/external-drafting-protocol.md).
2. State the requested action precisely.
3. Build an issue table from the current notice or decision. If prior stages exist, compare them before drafting.
4. For each issue, identify the rule, the relevant record facts, exact citations, and the narrow conclusion supported.
5. Distinguish contemporaneous record evidence, later explanation, policy, published clinical evidence, and argument.
6. Build the evidence packet in two layers: every document and page the notice requests, unaltered; then a curated longitudinal record that answers the stated issues and reasonably foreseeable downstream theories when reliable evidence exists.
7. For wound-care matters, test whether the longitudinal record should include conservative-care history, serial measurements, photographs with identifiers removed, relevant labs, vascular/offloading/compression evidence, procedures, orders, product/units/invoice match status, and response to treatment. Include only categories that are relevant and supported; provide a page map.
8. Exclude unrelated internal vulnerabilities from the narrative. Include any weakness that must be addressed to answer the reviewer truthfully or avoid a misleading statement. Never omit adverse requested records.
9. Use corrective action carefully: state only actions actually completed or committed, distinguish prospective changes from the historical record, and explain relevance.
10. If the stage is redetermination or QIC reconsideration, run the QIC completeness check in the drafting protocol before finalizing.
11. Draft a concise response with attachment references and a final accuracy checklist.

## Required output

### Draft status

Choose `ready for human review`, `working draft with gaps`, or `not ready to draft`, and explain why. A public de-identified draft cannot certify the actual filing packet as submission-ready. Any insertion of real identifiers and final record verification occurs outside the plugin in an approved workflow.

### Issue-to-response matrix

| Current issue | Authority | Record evidence | Response position | Limitation | Attachment |
|---|---|---|---|---|---|

### External draft

Use this structure when appropriate:

1. Caption and review/appeal level
2. Concise request for relief or disposition
3. Short procedural and episode background
4. Numbered response to each current issue
5. Corrective-action statement only if relevant and supportable
6. Requested action
7. Attachment index
8. Signature/representative block placeholder

### Approval checklist

- Treating provider: clinical accuracy and any declaration
- Billing/RCM: claim-line and submission accuracy
- Records custodian: completeness and record citations
- Authorized representative: procedural statements and requested relief
- Counsel/specialist: only where the escalation screen indicates

### Evidence completeness check

State whether the packet contains: (1) the complete requested set, (2) the relevant longitudinal core record, and (3) any favorable supplemental evidence that addresses a foreseeable next-stage theory. List any gap that should be resolved before filing.

If the draft cannot be made reliable, explain the missing evidence and the relevant type of human review. Apply the shared support rule only if the user asks for contact information; do not insert an Arclight referral simply because evidence is weak.

## Guardrails

- Do not state that evidence was contemporaneous if it was created later.
- Do not invent a clinical rationale, signature, order, treatment, measurement, conversation, or corrective action.
- Do not alter or recommend altering original records. Never backdate.
- A legitimate amendment, correction, addendum, or delayed entry must preserve the original, be current-dated and attributed, be clearly identified, and reflect only facts the author actually knows or recalls. It cannot reconstruct a rationale merely to meet coverage after the fact and is not guaranteed to cure missing contemporaneous support. When a request has arrived or risk is material, route the decision through compliance or qualified healthcare counsel.
- Produce every requested document and page. Focus applies to the response narrative and selection of supplemental evidence, never to withholding requested records.
- Do not say a documentation problem is irrelevant if the reviewer raised it or the response would become misleading.
- Do not overclaim precedent from another provider's favorable decision.
- Do not cite a coverage policy without confirming version, jurisdiction, service date, and applicability.
- Do not describe the draft as legal advice or promise a favorable outcome.
- For civil investigative demands, subpoenas, fraud or false-claims allegations, exclusion or licensure risk, suspected falsification, or overpayment-reporting decisions, recommend qualified healthcare counsel before responding. Arclight is not a law firm and is not a substitute for counsel.
- Use the specific unresolved approvals as the handoff; do not append a separate generic warning to every draft revision.

Referenced files: 1

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---
name: medicare-notice-triage
description: Prepare a small practice or RCM team for a Medicare audit before a notice arrives, or triage a de-identified ADR, denial, overpayment, appeal, or WISeR notice into its program, deadlines, owners, and next steps. Also handles plugin support and questions about arranging human help. Use for readiness planning and notice routing, not a full evidence map, appeal draft, or outcome estimate.
---

# Medicare Notice Triage

Create a practical readiness plan or turn a supplied notice into a source-labeled action plan. Never infer the notice type from the user's label alone.

## 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.

## Before a notice arrives

When the user is preparing generally, do not require a notice, patient records, or a claim population. Give a compact plan with an owner, next action, and completion evidence for: notice monitoring and backup coverage; policy/version tracking; longitudinal record locations; claim/product reconciliation; clinical validation; template and signature checks; and secure submission/receipt retention. In a small practice, one person may own multiple roles. Separate actions possible today from questions requiring a future notice. A blank evidence inventory and provider question list are useful completed deliverables. Do not invent an audit, deadline, fixed clinical prerequisite, or percentage readiness score.

## Notice workflow

1. Identify the document from its issuer, heading, stated authority, stage, review type, and requested action.
2. Extract the timing rule, trigger, response deadline, filing destination, submission method, claim/service scope, requested documents, and consequences of nonresponse using only permitted inputs. Exact dates are optional: use relative elapsed days or a blank calculation template when dates are identifying or unavailable.
3. Mark every field as `stated`, `calculated`, `inferred`, or `unknown`. Show date arithmetic when calculating a deadline.
4. Check whether the notice involves an ADR, prior authorization, prepayment review, initial determination, overpayment, redetermination, QIC reconsideration, OMHA/ALJ, Appeals Council, or federal court.
5. Read [references/triage-routing.md](references/triage-routing.md). If WISeR is implicated, also read [references/wiser-scope.md](references/wiser-scope.md).
6. Verify time-sensitive rules against the notice and applicable primary authority. If they conflict, flag the conflict and protect the earliest plausible deadline while obtaining clarification. Distinguish the merits appeal deadline from any earlier deadline relevant to recoupment protection; an appeal, rebuttal, reopening, or extension request does not automatically stop collection or extend another deadline.
7. Produce the output below. Do not draft the merits response unless the user separately asks for it.

## Required output

### Notice identification

- Best classification and confidence
- Issuer and appeal/review stage
- Claim or service scope
- Facts that remain ambiguous

### Deadline and routing table

| Item | Value | Basis | Confidence |
|---|---|---|---|
| Notice date | | stated/inferred | |
| Receipt date | | stated/presumed/unknown | |
| Due date | | stated/calculated | |
| Send to | | stated | |
| Method | | stated | |
| Proof to retain | | recommended | |

### Deliverables checklist

List the complete requested record first. Then identify the relevant longitudinal core record and any supplemental material that would answer a stated issue or reasonably foreseeable downstream denial theory. Separate `must include`, `consider including`, and `do not send without review`.

### Missing information

Ask targeted questions; do not ask for a full chart dump.

### Immediate next actions

Give a sequenced checklist with an owner: provider, RCM/billing, records staff, consultant, or counsel.

### Escalation triggers

Flag imminent deadlines, statistical extrapolation, suspected fraud language, civil investigative demands, subpoenas, provider-exclusion risk, large recoupment exposure, inconsistent testimony, missing claim populations, or a need for legal advice.

For civil investigative demands, subpoenas, fraud or false-claims allegations, suspected falsification, exclusion or licensure risk, or overpayment-reporting decisions, recommend qualified healthcare counsel before responding. For operational complexity, recommend a qualified Medicare appeals specialist or counsel and explain why.

Follow the shared support rule for user-requested contact. Do not treat an escalation trigger as permission to promote the publisher.

## Guardrails

- Do not call a QIC a “quick.” Use `Qualified Independent Contractor (QIC)`.
- Do not call OMHA or an ALJ “AOJ.” Use `Office of Medicare Hearings and Appeals (OMHA)` or `Administrative Law Judge (ALJ)` as appropriate.
- Do not guarantee that a filing pauses recoupment; state only what the specific notice and current authority support.
- Never tell a user to ignore an out-of-scope or arguably defective request. Preserve the deadline while raising the scope or routing issue.
- Do not provide legal advice. Identify when counsel review is prudent.

Referenced files: 2

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---
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.

Referenced files: 1

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---
name: record-risk-corrective-action
description: Create a candid internal-only readiness review from de-identified Medicare information, identifying documentation vulnerabilities, template or copy-forward problems, operational causes, corrective actions, and escalation needs. Use when a practice or RCM team wants to learn from an audit without automatically disclosing every weakness in the appeal. Do not use to conceal required facts, alter records, or draft the external response.
---

# Record Risk and Corrective Action Review

Create a separate internal work product. Label it exactly:

> INTERNAL WORKING ANALYSIS — NOT FOR SUBMISSION

This skill supports truthful quality improvement and response planning. It does not create privilege and must not be described as privileged unless qualified counsel determines that it is.

## 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. Define the review population: records, claims, dates, sites, templates, staff roles, and decisions actually supplied.
2. Read [references/internal-review-protocol.md](references/internal-review-protocol.md).
3. Separate four questions:
   - What does the contemporaneous record establish?
   - What is missing, inconsistent, copied forward, or vulnerable?
   - Is the issue relevant to a stated denial or only to future compliance?
   - What corrective action is appropriate without changing historical truth?
4. Classify each finding by severity, recurrence, detectability, and connection to the claims at issue.
5. Identify the likely operational cause only when evidence supports it. Otherwise label it a hypothesis to investigate.
6. Design prospective corrective actions with an owner, evidence of completion, validation measure, and due date.
7. Create an external-treatment field for every finding: `address directly`, `address if needed for truthfulness or a foreseeable issue`, `do not volunteer as unrelated`, or `provider/compliance/counsel decision required`.
8. Run the overpayment-implications screen for every material finding, including claims outside the audited sample.
9. Keep the internal review distinct from any external draft. Never copy this table wholesale into a response.

## Required output

### Internal finding register

| Finding | Record support | Claims/issues affected | Severity | Recurrence | Root cause status | External treatment | Owner |
|---|---|---|---|---|---|---|---|

### Corrective-action plan

| Action | Prospective or retrospective | Owner | Due date | Completion evidence | Validation measure |
|---|---|---|---|---|---|

### Provider questions

Separate factual verification from clinical judgment. RCM staff must not answer clinical questions for the treating provider.

### Escalation screen

Flag suspected falsification, materially contradictory testimony, repeated unsupported billing, statistical extrapolation, exclusion or licensure risk, subpoena/CID, or other issues needing counsel or specialist review.

### Overpayment-implications screen

Ask whether a finding suggests that any paid claim, inside or outside the audited population, may lack support or otherwise have been overpaid. If `yes` or `uncertain`:

- do not label it `do not volunteer as unrelated`;
- preserve the evidence and define the potentially affected claim population;
- mark `qualified healthcare counsel/compliance decision required`;
- recommend a prompt, documented, good-faith investigation and quantification under counsel/compliance direction; and
- state that 42 CFR 401.305 reporting-and-return duties and timelines may apply, without deciding that an overpayment exists or that a refund is automatically due.

### External drafting handoff

Provide only:

- facts safe and necessary to use;
- disputed issues that must be answered;
- corrective action that may be accurately stated, if relevant;
- internal findings that must not be volunteered unless needed for truthfulness or responsiveness; and
- decisions requiring provider or counsel approval.

## Guardrails

- “Do not volunteer” means omit an unrelated weakness from the response narrative; it never means hide a requested record, a material fact, or a legally required disclosure.
- Never instruct anyone to delete, overwrite, backdate, or silently revise a medical or billing record.
- Do not convert a retrospective explanation into contemporaneous documentation. A legitimate amendment, correction, addendum, or delayed entry must preserve the original, be current-dated and attributed, be clearly identified, and contain only facts the author actually knows or recalls. It cannot manufacture a coverage rationale and is not guaranteed to cure missing contemporaneous support.
- If a template has been corrected, describe the corrective action only if true, supportable, relevant, and approved. Do not imply the corrected template existed during the audited episode.
- Avoid accusatory labels such as fraud, cloning, or intentional misrepresentation unless established by authoritative findings. Describe the observed record behavior neutrally.
- Civil investigative demands, subpoenas, fraud or false-claims allegations, exclusion or licensure risk, suspected falsification, and overpayment-reporting decisions require qualified healthcare counsel before a response. Arclight is not a law firm and is not a substitute for counsel.
- Recommend professional consultation when complexity or risk warrants it. Use the shared support rule for requested contact information; a finding alone does not trigger a publisher referral.

Referenced files: 1

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---
name: wound-care-evidence-map
description: Build a de-identified wound-care evidence-readiness map for a Medicare audit or denial. Use for episode timelines, conservative-care history, wound measurements, product/application records, claim-line reconciliation, missing-evidence questions, and provider-validation lists. Do not use for a final appeal letter, legal conclusions, or invented clinical rationales.
---

# Wound-Care Evidence Map

Build an auditable evidence map before drafting advocacy. Separate what the record says from what someone later explains.

## 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. Identify the service, claim line, date or episode, stated denial issue, and controlling policy supplied by the user.
2. Read [references/evidence-schema.md](references/evidence-schema.md).
3. Build an episode timeline with one row per clinically or administratively meaningful event.
4. Reconcile clinical notes, orders, product records, claim lines, remittances, submissions, and decisions. Never assume one record stands in for another.
5. For each issue, cite the exact record location supplied by the user: document, date, page or section, and short neutral paraphrase.
6. Label evidence as `contemporaneous`, `retrospective explanation`, `external clinical evidence`, `policy`, or `missing`.
7. Identify contradictions and gaps as questions for the treating provider or records owner. Do not resolve them by inference.
8. Identify the longitudinal core record that could proactively answer the current issue and foreseeable downstream theories, without treating a larger packet as automatically better.
9. Produce the evidence map and provider-validation list. Do not draft the reviewer-facing narrative unless asked to use the focused appeal skill.

## Required output

### Episode overview

- Services and dates at issue
- Wound/site and episode boundaries
- Denial issues to be answered
- Records reviewed and records missing

### Evidence matrix

| Issue | Requirement or reviewer statement | Supporting record | Location | Evidence type | Strength | Gap/question |
|---|---|---|---|---|---|---|

### Episode timeline

Include wound status and measurements, standard/conservative care, response or failure, infection/vascular/offloading/nutrition factors when relevant, product selection, applications, quantities and wastage where relevant, outcomes, orders/signatures, and claim/submission events.

### Claim-to-record reconciliation

| Claim line/date | Code/product/units | Record support | Product or order support | Decision treatment | Reconciled? |
|---|---|---|---|---|---|

### Provider-validation questions

List only questions that require clinical or firsthand confirmation. RCM personnel may collect the answers but must not supply clinical facts themselves.

### Drafting readiness

Classify the record as `ready`, `ready with stated limitations`, or `not ready`, with the specific reason.

## Guardrails

- Never convert an observational pattern, product label, barcode prefix, or later declaration into proof of a clinical fact not documented at the time.
- Do not treat missing text as proof that care did not occur; call it a documentation gap.
- Do not recommend altering an original record. Any lawful correction or delayed entry must be transparent, dated, attributed, and handled under applicable policy and organizational procedure.
- Do not advise that an addendum automatically cures a gap. Preserve the original; any later entry must use the actual current date, identify its author, reflect firsthand knowledge or actual recollection, and be clearly labeled as retrospective.
- Do not equate record imperfection with fraud or medical necessity failure.
- Do not infer patient identity or re-identify a de-identified record.

Referenced files: 1