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DenialPath

by io.github.maxbeech

Scrub a claim against NCCI PTP and MUE edits

check_claim
Read-onlyIdempotent

Scrub a claim against the NCCI procedure-to-procedure (PTP) edits and medically unlikely edits (MUE) in force on its date of service. Deterministic: no model, so identical input always returns an identical verdict. Every finding.status is one of pass (checked against a real edit and clean), fail (an edit fires), bypassed (an edit fires but a modifier already on the line legitimately resolves it), or no_data (we hold no edit for this code or pair in our dataset). no_data is NOT a pass: treat it as unchecked, since CMS may still deny the line under an edit outside our loaded subset. summary.clean is true only when every finding is pass and none are no_data - never report a claim clean because nothing failed if some lines were never checked. The response echoes editQuarter (the CMS quarter version the verdict was computed against) and coverage (how many PTP pairs and MUE codes are loaded), so you can tell a caller exactly what was checked. Free, no API key needed; a key only raises the rate limit.

Input Schema

TableJSON Schema
NameRequiredDescriptionDefault
linesYesThe billed lines on this claim.
payerSlugNoOptional payer slug for context. Does not change the PTP/MUE verdict.
dateOfServiceYesISO yyyy-mm-dd, e.g. "2026-07-01". Selects which CMS edit quarter applies.

Schema Changelog

Changes observed during successful MCP inspections. Dates show when Glama detected each change.

  1. Changed3 schema fields changed
    • changedInput schema / properties / dateOfService / description
      Previous value: -"ISO yyyy-mm-dd. Selects which CMS edit quarter applies."New value: +"ISO yyyy-mm-dd, e.g. \"2026-07-01\". Selects which CMS edit quarter applies."
    • addedInput schema / properties / dateOfService / format
      Added value: +"date"
    • addedInput schema / properties / dateOfService / pattern
      Added value: +"^\\d{4}-\\d{2}-\\d{2}$"
  2. First observed

TDQS

B3.4/5.0
Behavior1/5

Does the description disclose side effects, auth requirements, rate limits, or destructive behavior?

The description contradicts the openWorldHint annotation. openWorldHint=false implies a closed world where absence of data is conclusive, but the description explicitly warns that no_data is NOT a pass and that CMS may still deny under edits outside the loaded subset. This is an open-world behavior, directly conflicting with the annotation.

Agents need to know what a tool does to the world before calling it. Descriptions should go beyond structured annotations to explain consequences.

Conciseness4/5

Is the description appropriately sized, front-loaded, and free of redundancy?

The description is longer than average but earns its length by explaining the nuanced status values and the no_data caveat. It is front-loaded with the main verb and resource, and every sentence adds necessary behavioral detail. Slightly verbose but justified.

Shorter descriptions cost fewer tokens and are easier for agents to parse. Every sentence should earn its place.

Completeness5/5

Given the tool's complexity, does the description cover enough for an agent to succeed on first attempt?

Despite no output schema, the description thoroughly explains the response semantics: each finding.status, summary.clean rules, and the echoed editQuarter/coverage fields. It also covers edge cases (no_data not a pass) and constraints (free, rate limit). This is a complete picture for an agent to invoke and interpret results.

Complex tools with many parameters or behaviors need more documentation. Simple tools need less. This dimension scales expectations accordingly.

Parameters3/5

Does the description clarify parameter syntax, constraints, interactions, or defaults beyond what the schema provides?

Schema coverage is 100%, so the schema already documents all parameters (dateOfService, lines, payerSlug). The description adds some context (e.g., dateOfService selects the edit quarter, modifiers resolve bypassed), but it does not significantly enhance parameter meaning beyond the schema. Baseline 3 is appropriate.

Input schemas describe structure but not intent. Descriptions should explain non-obvious parameter relationships and valid value ranges.

Purpose5/5

Does the description clearly state what the tool does and how it differs from similar tools?

The description opens with a specific verb and resource: 'Scrub a claim against the NCCI procedure-to-procedure (PTP) edits and medically unlikely edits (MUE)'. This clearly differentiates from siblings like get_ncci_edits, get_mue, explain_denial, etc., which focus on retrieving edits or explaining denials rather than checking a full claim.

Agents choose between tools based on descriptions. A clear purpose with a specific verb and resource helps agents select the right tool.

Usage Guidelines3/5

Does the description explain when to use this tool, when not to, or what alternatives exist?

The description provides clear context about when the tool is relevant (checking a claim against NCCI edits) but does not explicitly state when NOT to use it or recommend alternatives. The deterministic and free notes are usage benefits, but no direct comparison to sibling tools is made.

Agents often have multiple tools that could apply. Explicit usage guidance like "use X instead of Y when Z" prevents misuse.

All DenialPath toolsInspect
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TDQS

A4.2/5.0
Disambiguation5/5

Each tool targets a distinct function: claim checking, appeal drafting, denial explanation, MUE lookup, NCCI edits lookup, and timely filing. There is no overlap in purpose, and the descriptions make the boundaries clear.

Naming Consistency5/5

All tool names follow a consistent verb_noun pattern (check_claim, draft_appeal, explain_denial, get_mue, get_ncci_edits, get_timely_filing). The verbs are specific and the nouns are meaningful, creating a predictable and readable naming scheme.

Tool Count5/5

Six tools is well within the ideal range for a focused server. The count feels appropriate for the denial management domain, with each tool earning its place and no redundancy.

Completeness5/5

The toolset covers the full denial lifecycle: pre-claim checking (check_claim), denial explanation (explain_denial), appeal drafting (draft_appeal), and supporting lookups (get_mue, get_ncci_edits, get_timely_filing). No obvious gaps exist for the stated purpose.

Resources