Insurance Claims

insurance-claims

Deterministic, API-first insurance claims workflow skill.

Setup check — do this first

Before doing anything else, verify the Stedi API key is available:

python -c "from scripts.config import get_api_key; print('API key OK')"

Run this from the insurance-claims/ directory. If it prints API key OK, proceed normally.

If it raises an error (key missing or empty), stop and guide the user through setup:

1. Get the key — direct the user to app.stedi.com/app/settings/api-keys.

   • They'll need to log in (or create a free account at stedi.com).
   • On the API Keys page, click Create API key, give it a name (e.g. ona-health), and copy the key.

2. Save the key — open the .env file at the repo root (ona-health-skills/.env) and set:

   STEDI_API_KEY=your-key-here
   

   The .env file is gitignored, so the key will not be committed to source control.

3. Verify — re-run the check above. Once it prints API key OK, continue with the original task.

If the user is unsure where the repo root is, run pwd from the skill directory and show them the path.

Operating principles

1. Use Stedi API + deterministic scripts for validations, submissions, status checks, and retrieval workflows.
2. Prefer structured JSON inputs/outputs. Avoid ad-hoc, ambiguous steps.
3. Run a requirements preflight before claim actions (payer support, enrollment status, provider identifiers, environment safety).
4. Fail fast with actionable remediation steps when prerequisites are not met.
5. Keep PHI exposure minimal in logs and outputs.

Read path (progressive disclosure)

Start with:

• references/stedi-overview.md

Then read only what is needed:

• Submission design: references/stedi-submitting-claims.md
• Response handling: references/stedi-claim-responses.md
• Practical constraints: references/stedi-best-practices.md
• Rejections/resubmissions lifecycle: references/stedi-claim-lifecycle.md
• Enrollment/payer requirements: references/stedi-enrollment-and-payers.md
• Test workflows: references/stedi-testing.md
• Attachments and MCP context: references/stedi-attachments-and-mcp.md
• Provider/payer requirement preflight: references/provider-requirements.md

Deterministic workflow

Follow this sequence unless user explicitly requests otherwise.

1. Classify task

   • One of: validate_claim, submit_claim, check_claim_status, lookup_payer, retrieve_277ca, retrieve_835era, poll_transactions, resubmit_or_void.

2. Run preflight requirements check

   • Resolve payer ID.
   • Verify transaction support.
   • Verify enrollment requirement and status.
   • Verify provider identifiers (NPI and any payer-specific requirements).
   • Verify environment consistency (test vs production).
   • If any check fails, stop and return deterministic remediation.

3. Use script stubs/interfaces (or real implementation when present)

   • scripts/validate_claim.py
   • scripts/submit_claim.py
   • scripts/check_claim_status.py
   • scripts/lookup_payer.py
   • scripts/retrieve_277ca.py
   • scripts/retrieve_835era.py
   • scripts/poll_transactions.py

4. Correlate all transactions

   • Primary key: patientControlNumber.
   • Secondary key: Stedi correlationId.
   • Line-level key: service-line control number.

5. Return structured output

   • Include status summary, key identifiers, and next action suggestions.

Script usage contract

Use these interfaces unless user requests a different shape.

• validate_claim.py

  • Input: JSON payload path
  • Output:

    { "valid": true, "errors": [], "warnings": [] }
    

• submit_claim.py

  • Input: claim type (professional|institutional|dental), payload, optional test flag
  • Output:

    {
      "status": "SUCCESS",
      "correlationId": "...",
      "patientControlNumber": "...",
      "errors": []
    }
    

• check_claim_status.py

  • Output:

    {
      "claims": [
        { "statusCategoryCode": "...", "statusCode": "...", "description": "..." }
      ]
    }
    

• lookup_payer.py

  • Output:

    {
      "payers": [
        { "payerId": "...", "name": "...", "aliases": [], "supportedTransactions": [] }
      ]
    }
    

• retrieve_277ca.py / retrieve_835era.py / poll_transactions.py

  • Return normalized, parser-friendly objects with deterministic fields.

Required guardrails

• Authentication: read API key from STEDI_API_KEY.
• Always include idempotency keys on submission requests.
• Validate PCN format (alphanumeric, <=17 chars) and uniqueness.
• Avoid reserved delimiter characters in JSON data where applicable.
• Use usageIndicator: "T" for test submissions and "P" for production.
• Do not claim adjudication outcome from 277CA alone.
• Treat duplicate webhooks/responses as normal; deduplicate by transaction and payment trace keys.

Resubmission policy

When user asks to fix/retry/cancel claims:

• Use lifecycle rules in references/stedi-claim-lifecycle.md.
• Determine if claim entered payer system before choosing frequency code.
• Include PCCN where required for replacement/void flows.
• Generate a new PCN on each resubmission.

Output format for user responses

When performing claims tasks, return:

1. What I did (short)
2. Result (status + key IDs)
3. Why (if rejected/blocked)
4. Next actions (numbered, deterministic)

Example:

{
  "action": "submit_claim",
  "status": "blocked",
  "reason_code": "ENROLLMENT_REQUIRED",
  "context": {
    "providerNpi": "1999999984",
    "payerId": "6400",
    "transactionType": "835"
  },
  "nextActions": [
    "Submit enrollment request for 835",
    "Wait for enrollment status live",
    "Retry submission with same validated payload structure"
  ]
}

What to avoid

• Do not skip preflight checks for payer/provider requirements.
• Do not use vague advice when a deterministic action is possible.
• Do not expose full PHI payloads unless user explicitly requests and context is safe.
• Do not mix test and production assumptions in one run.