Deterministic CMS NCCI/MUE claim scrubbing and CARC/RARC denial explanations, cited to source.
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https://denialpath.vercel.app/api/mcp6 tools · 166mscheck_claimScrub 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 (a…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 (a…
of service. Deterministic: no model, so identical input always returns an identical verdict.…| Parameter | Type | Description |
|---|---|---|
| dateOfService* | string | ISO yyyy-mm-dd, e.g. "2026-07-01". Selects which CMS edit quarter applies. |
| payerSlug | string | Optional payer slug for context. Does not change the PTP/MUE verdict. |
| lines* | array | The billed lines on this claim. |
explain_denialExplain a CARC (Claim Adjustment Reason Code) and any RARCs (Remittance Advice Remark Codes) from a remittance: plain meaning, ranked corrective actions, and whether an appeal is worth filing. found:false means we do not hold that CARC in our dataset (X12 publishes far more codes than we have curat…Explain a CARC (Claim Adjustment Reason Code) and any RARCs (Remittance Advice Remark Codes) from a remittance: plain meaning, ranked corrective actions, and whether an appeal is worth filing. found:false means we do not hold that CARC in our dataset (X12 publishes far more codes than we have curat…
| Parameter | Type | Description |
|---|---|---|
| carc* | string | CARC code, with or without a group prefix, e.g. "CO-45" or "45". |
| rarc | array | Optional RARC codes on the same remittance line. |
| payer | string | Optional payer slug, to attach a timely-filing appeal deadline. |
get_ncci_editsLook up NCCI procedure-to-procedure (PTP) edits, in two modes. Pair mode: pass column1, column2 (either order) and dateOfService to check whether that specific pair bundles on that date; status is no_data (we hold no edit for this pair in our dataset - NOT confirmation CMS has none), not_applicable…Look up NCCI procedure-to-procedure (PTP) edits, in two modes. Pair mode: pass column1, column2 (either order) and dateOfService to check whether that specific pair bundles on that date; status is no_data (we hold no edit for this pair in our dataset - NOT confirmation CMS has none), not_applicable…
| Parameter | Type | Description |
|---|---|---|
| column1 | string | Pair mode: a CPT/HCPCS code. Send with column2 and dateOfService. Column order does not matter; the response reports the pair in CMS column order. |
| column2 | string | Pair mode: the other code in the pair. |
| dateOfService | string | Pair mode, required: ISO yyyy-mm-dd, e.g. "2026-07-01". NCCI PTP edits are versioned quarterly, so a pair lookup cannot be answered without a date. |
| code | string | List mode: a single code. Returns every pair in the dataset involving it, in either column, with no date filtering. |
get_mueLook up the medically unlikely edit (MUE) unit limit for a single CPT/HCPCS code. status is found or no_data; no_data means we hold no MUE value for this code in our dataset, not that CMS publishes none. When found, the returned limit.mai (adjudication indicator: "1" line edit - denies the excess u…Look up the medically unlikely edit (MUE) unit limit for a single CPT/HCPCS code. status is found or no_data; no_data means we hold no MUE value for this code in our dataset, not that CMS publishes none. When found, the returned limit.mai (adjudication indicator: "1" line edit - denies the excess u…
| Parameter | Type | Description |
|---|---|---|
| code* | string | CPT/HCPCS code, e.g. "36415". |
draft_appealGenerate an appeal letter for a denial, assembled deterministically from cited facts. REQUIRES A PRO OR SCALE PLAN. Called by an anonymous caller or a key on the free plan, this returns an upgrade_required error naming the pricing page - it never fabricates or partially generates a letter for a cal…Generate an appeal letter for a denial, assembled deterministically from cited facts. REQUIRES A PRO OR SCALE PLAN. Called by an anonymous caller or a key on the free plan, this returns an upgrade_required error naming the pricing page - it never fabricates or partially generates a letter for a cal…
| Parameter | Type | Description |
|---|---|---|
| carc* | string | CARC code from the remittance, e.g. "CO-45" or "45". |
| rarc | array | Optional RARC codes on the same remittance line. |
| payerSlug | string | Optional payer slug, to cite that payer's appeal policy and window. |
| providerName | string | Optional. Rendered as a placeholder if omitted. |
| claimNumber | string | Optional. Rendered as a placeholder if omitted. |
| dateOfService | string | Optional, ISO yyyy-mm-dd. Rendered as a placeholder if omitted. |
| codes | array | Optional procedure codes at issue, numeric reference only. |
| practiceNote | string | Optional free-text detail from the practice, appended to the argument section. |
get_timely_filingDays remaining to file an initial claim (or, if already past, how far over) for a payer given a date of service. daysRemaining and expired are null when we hold no published timely filing limit for that payer, which is common since many limits are contract-specific - check note before treating the…Days remaining to file an initial claim (or, if already past, how far over) for a payer given a date of service. daysRemaining and expired are null when we hold no published timely filing limit for that payer, which is common since many limits are contract-specific - check note before treating the…
| Parameter | Type | Description |
|---|---|---|
| payer* | string | Payer slug, e.g. "aetna". |
| dateOfService* | string | ISO yyyy-mm-dd, e.g. "2026-01-15". |
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Deterministic CMS NCCI/MUE claim scrubbing and CARC/RARC denial explanations, cited to source.
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