coverage-rights

get_appeal_rights

Read-onlyIdempotent

Deterministically resolve the governing appeal route, missing facts, filing recipient, deadlines, current external-review status, and verified grounds. Distinguishes Original Medicare, Medicare Advantage medical benefits, Part D pharmacy benefits, employer funding/governance, ACA, Medicaid, FEHB, TRICARE, and unknown coverage; unsupported or ambiguous routes fail closed.

Input Schema

TableJSON Schema

Name	Required	Description
`state`	No	Two-letter state code, e.g. 'ca'
`program`	Yes	Plan type
`appeal_stage`	No
`drug_channel`	No	For a drug denial, whether the medical or pharmacy benefit applies
`insurer_slug`	No	Insurer slug for insurer-specific stats
`denial_reason`	Yes	Denial reason category. Use 'prescription-drug' for medication denials — formulary exclusion, step therapy, quantity limits, or drug prior authorization — which return the formulary-exception grounds and their short decision deadlines.
`employer_type`	No	Required to resolve job-based coverage
`current_status`	No
`funding_status`	No	Required to resolve job-based state versus federal governance
`regulatory_marker`	No
`regulatory_state_basis`	No

Schema Changelog

Changes observed during successful MCP inspections.

Changed8 schema fields changedAug 1, 2026

addedInput schema / properties / appeal_stage

Added value: +{
+  "enum": [
+    "initial-denial",
+    "internal-appeal-filed",
+    "first-internal-denial",
+    "final-internal-denial",
+    "external-review-filed",
+    "unknown"
+  ],
+  "type": "string"
+}

addedInput schema / properties / current_status

Added value: +{
+  "enum": [
+    "awaiting-service",
+    "receiving-service",
+    "service-ended",
+    "post-service-claim",
+    "unknown"
+  ],
+  "type": "string"
+}

addedInput schema / properties / drug_channel

Added value: +{
+  "description": "For a drug denial, whether the medical or pharmacy benefit applies",
+  "enum": [
+    "not-a-drug",
+    "medical-benefit",
+    "pharmacy-benefit",
+    "unknown"
+  ],
+  "type": "string"
+}

addedInput schema / properties / employer_type

Added value: +{
+  "description": "Required to resolve job-based coverage",
+  "enum": [
+    "private",
+    "government",
+    "church",
+    "union",
+    "unknown"
+  ],
+  "type": "string"
+}

addedInput schema / properties / funding_status

Added value: +{
+  "description": "Required to resolve job-based state versus federal governance",
+  "enum": [
+    "fully-insured",
+    "self-funded",
+    "unknown"
+  ],
+  "type": "string"
+}

changedInput schema / properties / program / enum

Previous value: -[
-  "medicare-advantage",
-  "erisa-employer-plans",
-  "aca-marketplace",
-  "medicaid"
-]New value: +[
+  "medicare-advantage",
+  "original-medicare",
+  "medicare-part-d",
+  "erisa-employer-plans",
+  "aca-marketplace",
+  "medicaid",
+  "fehb",
+  "tricare",
+  "other-unknown"
+]

addedInput schema / properties / regulatory_marker

Added value: +{
+  "enum": [
+    "state-regulated",
+    "federal-or-self-funded",
+    "unknown"
+  ],
+  "type": "string"
+}

addedInput schema / properties / regulatory_state_basis

Added value: +{
+  "enum": [
+    "denial-letter",
+    "insurance-card",
+    "plan-document",
+    "residence-only",
+    "unknown"
+  ],
+  "type": "string"
+}

Changed2 schema fields changedJul 30, 2026

changedInput schema / properties / denial_reason / description

Previous value: -"Denial reason category"New value: +"Denial reason category. Use 'prescription-drug' for medication denials — formulary exclusion, step therapy, quantity limits, or drug prior authorization — which return the formulary-exception grounds and their short decision deadlines."

changedInput schema / properties / denial_reason / enum

Previous value: -[
-  "medical-necessity",
-  "experimental-investigational",
-  "prior-authorization",
-  "out-of-network",
-  "not-covered-benefit",
-  "coding-billing-error"
-]New value: +[
+  "medical-necessity",
+  "experimental-investigational",
+  "prior-authorization",
+  "out-of-network",
+  "not-covered-benefit",
+  "coding-billing-error",
+  "prescription-drug"
+]

First observedJul 19, 2026

TDQS

A4.2/5.0

Behavior5/5

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

Annotations already declare read-only, idempotent, and non-destructive behavior. The description adds meaningful behavioral context beyond annotations: deterministic resolution, fail-closed handling for unsupported or ambiguous routes, and the specific coverage categories it distinguishes. No contradiction is present.

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

Conciseness5/5

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

The description is two dense sentences with no filler. The front-loaded verb 'Deterministically resolve' immediately communicates the action, and every phrase contributes to scope, output, or behavioral boundaries.

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

Completeness4/5

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

For an 11-parameter tool with no output schema, the description still lists the returned categories (appeal route, missing facts, filing recipient, deadlines, external-review status, verified grounds) and coverage scope. It is sufficient for selection and invocation, though it does not explain parameter prerequisites or offer usage examples.

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 descriptions cover 64% of parameters and most parameters have enums, so the structured schema does much of the work. The description reinforces the coverage-program taxonomy and denial reasons but does not add per-parameter syntax or clarify undocumented fields like state or current_status beyond what enums imply.

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 'Deterministically resolve the governing appeal route, missing facts, filing recipient, deadlines, current external-review status, and verified grounds,' providing a specific verb and clear object. It distinguishes this tool from siblings like get_state_external_review and get_insurer_metrics by enumerating coverage programs and appeal-route scope.

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?

There is no explicit 'use when' or 'use instead' guidance. The intended context is inferable from the coverage list and appeal-route focus, but exclusions and alternatives are not stated, so guidance is only implied.

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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