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What a claim denial code means

denial_code_lookup
Read-onlyIdempotent

What an insurance or Medicare denial code on an explanation of benefits means: a Claim Adjustment Reason Code (e.g. CO-97, PR-1, 197) or a Remark Code (e.g. M15, N432), from the X12 code lists. With a prefix it says whether the person may owe the amount (CO is the provider's write-off, PR is patient responsibility); for common codes it gives the typical fix and who acts. Not legal or billing advice.

Tool call template

Replace each placeholder with a value matching the input schema. Only required parameters are included; add optional parameters as needed.

{
  "id": 1,
  "jsonrpc": "2.0",
  "method": "tools/call",
  "params": {
    "arguments": {
      "code": "<code>"
    },
    "name": "denial_code_lookup"
  }
}

Input Schema

NameRequiredDescriptionDefault
codeYesThe code as printed, e.g. CO-97, PR-204, 50 or N432.

Schema Changelog

Changes observed during successful MCP inspections.

  1. First observed

TDQS

A3.8/5.0
Behavior3/5

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

Annotations already declare readOnlyHint, idempotentHint, destructiveHint=false, and openWorldHint=false, and the description is consistent with a pure lookup. It adds useful behavioral context — prefix semantics (CO vs PR) and that only common codes get fix guidance — but does not state coverage gaps, unknown-code behavior, or versioning of the X12 code lists.

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?

One dense sentence plus a scope disclaimer; the core decode purpose is front-loaded. The parenthetical examples and prefix explanation earn their place, though the sentence is long and slightly packed.

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

Completeness3/5

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

For a one-parameter read-only lookup with full schema coverage, the essentials are present, but it omits what happens with unrecognized or obsolete codes and gives no sense of result shape beyond 'typical fix' for common codes. No output schema exists, so a brief note on returned fields would help.

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% and the single parameter is documented in the schema with examples matching those in the description. The description adds the notion of an optional prefix and alternate formats, but mostly repeats the schema's examples, so baseline 3 applies.

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?

States a specific verb and resource: decodes what a denial code on an EOB means, naming both code families (Claim Adjustment Reason Code, Remark Code) with examples. It is clearly distinguishable from siblings like hcpcs_lookup or appeal_deadline.

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

Usage Guidelines4/5

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

Implicitly scopes usage to interpreting printed denial codes from an EOB and mentions what the answer contains (whether the patient may owe, typical fix, who acts). It does not explicitly say when to prefer a different tool, though the sibling names differ enough that overlap risk is low.

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

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