Catches the denial before it happens. Skills for detecting payer behavior shifts, denial pattern prevention, and care operations intelligence.
Pre-submission claim risk. Denial decoding. Denial routing. Appeal drafting. Payer intel. Payer behavior. Auth readiness. NCCI conflict resolution. Inside Claude Code, no context switching.
| Skill | Trigger | What it does |
|---|---|---|
| Denial Decoder | /denial-decoder <code> |
Plain English explanation of any CARC or RARC code with the corrective action. |
| Denial Router | /denial-router |
Root-cause classification + routing to billing, clinical, or authorization team with urgency level. |
| Appeal Drafter | /appeal-drafter |
Payer specific appeal letter with regulatory grounding and the right citation density. |
| Claim Scanner | /claim-scanner |
Pre-submission risk scan. NCCI edits, denial probability, authorization flags, payer behavioral context. |
| Auth Readiness | /auth-readiness |
Pre-submission prior-auth readiness score (0-100) with risk factors and fix instructions. ABA, Dental, PT/OT, SNF. |
| Payer Intel | /payer-intel <payer> |
Denial rates, authorization quirks, submission strategy by specialty. |
| Payer Behavior | /payer-behavior <payer> |
Current behavior patterns, cluster classification, recent policy changes, and what actions work against them. |
| NCCI Checker | /ncci-checker <cpt1> <cpt2> |
CPT pair conflict check with modifier resolution paths. |
Works across ABA, SNF, PT/OT, dental, dialysis, imaging, home health, and behavioral health.
claude skills install https://github.com/Upstream-Intelligence/upstream-skillsOr clone and reference locally:
git clone https://github.com/Upstream-Intelligence/upstream-skillsOut of the box, these skills work standalone. Claude uses its built in healthcare billing knowledge to respond.
Install upstream-mcp to get live data:
- Real NCCI edit tables (refreshed quarterly)
- Live payer denial rates and A to F grades
- Fee schedule lookups against current CMS rates
- Pre-submission claim risk scores against the operator network
claude mcp add upstream -- npx -y @upstream-intelligence/mcp
export UPSTREAM_API_KEY=your_key_hereFree API key (500 calls per month, no credit card): upstream.cx/developers/keys
- "Decode CARC 97 on a home health claim and tell me how to fix it."
- "Check if CPT 97153 and 97155 can be billed together for UnitedHealthcare."
- "Draft an appeal for Aetna denying my CARC 50 claim with the supporting medical necessity citations."
- "How does Cigna's denial rate compare to UnitedHealthcare for this specialty?"
- "Scan this claim before I submit. Payer Aetna. CPT 97153, 97155. Dx F84.0."
- "What payer is the worst Slow Payer in my book this quarter?"
The skills handle the structure. Claude handles the response. The MCP supplies the data when it is installed.
Healthcare billing teams spend most of the week on a small set of high-stakes, repeated tasks. Scrubbing claims before submission. Routing denials to the right team. Drafting appeals. Looking up payer rules and behavior. Checking prior-auth readiness. Resolving NCCI conflicts. Every other workflow is a variation on one of these.
Each skill compresses what used to be a 15 minute task into a 30 second prompt. Multiplied across a billing team, that compounds into double digit hours back per week.
Do I have to use the MCP? No. The skills work standalone. The MCP makes them sharper because Claude calls real Upstream data instead of relying on training data.
Does this work for any specialty? Yes. The skills cover ABA, SNF, PT/OT, dental, dialysis, imaging, home health, and behavioral health. Specialty context is inferred from the prompt or set explicitly with a flag.
What does this cost? The skills are MIT licensed. Free. The MCP free tier gives you 500 calls per month at no cost. Pioneer beta is $49 per month for 5,000 calls.
What if I do not use Claude Code?
The skills are designed for Claude Code's skills install flow. With upstream-mcp installed in Claude Desktop, you can still invoke the underlying tools directly from a Desktop conversation — they just are not packaged as slash commands there.
Can I customize the appeal letter templates? Yes. Each skill is a Markdown file. Fork, edit, install your customized version.
Part of the Upstream Intelligence ecosystem.
- upstream-mcp — MCP server for Claude
- upstream-skills — you are here
- upstream-community — open ML methodology
- awesome-payer-risk — curated RCM resources
Product: upstream.cx · Newsletter · Pricing
Built by Upstream Intelligence. Read the methodology at engine.upstream.cx. Pioneer Program: upstream.cx/pioneer.
upstream.cx · hello@upstream.cx
Care Intelligence Platform.