{"id":28255,"plugin_id":"plugins_6abd61cbd2148191a8dceb8261e8cf4e","kind":"skill","collection_source":"plugin_package","comparison_source":null,"observed_at":"2026-10-08T18:03:24.048Z","digest":"183e28a07cb8d1f0ebd560845b88324788c61bf27a2f03b0d3962150437dc703","against":null,"payload":{"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.","included_files":[{"relative_path":"references/external-drafting-protocol.md","size_in_bytes":6849}],"name":"focused-appeal-response","skill_md_contents":"---\nname: focused-appeal-response\ndescription: 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.\n---\n\n# Focused Appeal Response\n\nWrite a truthful, issue-led external submission. Use the decision's actual rationale, not a generic medical-necessity argument.\n\n## Scope\n\nThis 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.\n\n## Entry criteria\n\nBefore drafting, require:\n\n- a de-identified notice or accurate statement of the current issues;\n- appeal/review level and deadline;\n- claim or episode scope;\n- record citations for material factual statements;\n- the controlling policy or a plan to verify it; and\n- provider validation for clinical facts supplied by nonclinical staff.\n\nIf these are incomplete, produce a drafting plan and missing-information list instead of a polished final letter.\n\n## Shared operating rules\n\nRead 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.\n\n## Workflow\n\n1. Read [references/external-drafting-protocol.md](references/external-drafting-protocol.md).\n2. State the requested action precisely.\n3. Build an issue table from the current notice or decision. If prior stages exist, compare them before drafting.\n4. For each issue, identify the rule, the relevant record facts, exact citations, and the narrow conclusion supported.\n5. Distinguish contemporaneous record evidence, later explanation, policy, published clinical evidence, and argument.\n6. 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.\n7. 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.\n8. 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.\n9. Use corrective action carefully: state only actions actually completed or committed, distinguish prospective changes from the historical record, and explain relevance.\n10. If the stage is redetermination or QIC reconsideration, run the QIC completeness check in the drafting protocol before finalizing.\n11. Draft a concise response with attachment references and a final accuracy checklist.\n\n## Required output\n\n### Draft status\n\nChoose `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.\n\n### Issue-to-response matrix\n\n| Current issue | Authority | Record evidence | Response position | Limitation | Attachment |\n|---|---|---|---|---|---|\n\n### External draft\n\nUse this structure when appropriate:\n\n1. Caption and review/appeal level\n2. Concise request for relief or disposition\n3. Short procedural and episode background\n4. Numbered response to each current issue\n5. Corrective-action statement only if relevant and supportable\n6. Requested action\n7. Attachment index\n8. Signature/representative block placeholder\n\n### Approval checklist\n\n- Treating provider: clinical accuracy and any declaration\n- Billing/RCM: claim-line and submission accuracy\n- Records custodian: completeness and record citations\n- Authorized representative: procedural statements and requested relief\n- Counsel/specialist: only where the escalation screen indicates\n\n### Evidence completeness check\n\nState 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.\n\nIf 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.\n\n## Guardrails\n\n- Do not state that evidence was contemporaneous if it was created later.\n- Do not invent a clinical rationale, signature, order, treatment, measurement, conversation, or corrective action.\n- Do not alter or recommend altering original records. Never backdate.\n- 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.\n- Produce every requested document and page. Focus applies to the response narrative and selection of supplemental evidence, never to withholding requested records.\n- Do not say a documentation problem is irrelevant if the reviewer raised it or the response would become misleading.\n- Do not overclaim precedent from another provider's favorable decision.\n- Do not cite a coverage policy without confirming version, jurisdiction, service date, and applicability.\n- Do not describe the draft as legal advice or promise a favorable outcome.\n- 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.\n- Use the specific unresolved approvals as the handoff; do not append a separate generic warning to every draft revision.\n"},"changes":[],"summary":"First saved snapshot. No earlier version is available for comparison.","summary_kind":"deterministic","summary_metadata":{}}