MCPサーバー
coverage-rights
com.coverage-rights/coverage-rights
このMCPでできること
Provides health-insurance denial metrics, treatment and condition appeal outcomes, drug appeal guidance, and coverage appeal procedures.
機能
ツール
9
ツール
get_appeal_rights
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.
読み取り専用
冪等
入力スキーマ
{'type': 'object', '$schema': 'http://json-schema.org/draft-07/schema#', 'required': ['program', 'denial_reason'], 'properties': {'state': {'type': 'string', 'maxLength': 2, 'minLength': 2, 'description': "Two-letter state code, e.g. 'ca'"}, 'program': {'enum': ['medicare-advantage', 'original-medicare', 'medicare-part-d', 'erisa-employer-plans', 'aca-marketplace', 'medicaid', 'fehb', 'tricare', 'other-unknown'], 'type': 'string', 'description': 'Plan type'}, 'appeal_stage': {'enum': ['initial-denial', 'internal-appeal-filed', 'first-internal-denial', 'final-internal-denial', 'external-review-filed', 'unknown'], 'type': 'string'}, 'drug_channel': {'enum': ['not-a-drug', 'medical-benefit', 'pharmacy-benefit', 'unknown'], 'type': 'string', 'description': 'For a drug denial, whether the medical or pharmacy benefit applies'}, 'insurer_slug': {'type': 'string', 'description': 'Insurer slug for insurer-specific stats'}, 'denial_reason': {'enum': ['medical-necessity', 'experimental-investigational', 'prior-authorization', 'out-of-network', 'not-covered-benefit', 'coding-billing-error', 'prescription-drug'], 'type': 'string', 'description': "Denial reason category. Use 'prescription-drug' for medication denials â\x80\x94 formulary exclusion, step therapy, quantity limits, or drug prior authorization â\x80\x94 which return the formulary-exception grounds and their short decision deadlines."}, 'employer_type': {'enum': ['private', 'government', 'church', 'union', 'unknown'], 'type': 'string', 'description': 'Required to resolve job-based coverage'}, 'current_status': {'enum': ['awaiting-service', 'receiving-service', 'service-ended', 'post-service-claim', 'unknown'], 'type': 'string'}, 'funding_status': {'enum': ['fully-insured', 'self-funded', 'unknown'], 'type': 'string', 'description': 'Required to resolve job-based state versus federal governance'}, 'regulatory_marker': {'enum': ['state-regulated', 'federal-or-self-funded', 'unknown'], 'type': 'string'}, 'regulatory_state_basis': {'enum': ['denial-letter', 'insurance-card', 'plan-document', 'residence-only', 'unknown'], 'type': 'string'}}, 'additionalProperties': False}
get_condition_outcomes
External-review outcomes for a medical condition: how often insurance denials involving this condition were overturned, plus the most-fought treatments for it.
読み取り専用
冪等
入力スキーマ
{'type': 'object', '$schema': 'http://json-schema.org/draft-07/schema#', 'required': ['slug'], 'properties': {'slug': {'type': 'string', 'description': "Condition slug, e.g. 'obesity', 'autism', 'hepatitis-c'"}}, 'additionalProperties': False}
get_drug_playbook
Drug-specific denial patterns and appeal strategy for the medications plans fight hardest over: GLP-1s (Wegovy, Zepbound, Mounjaro, Ozempic, Saxenda) and IBD biologics (Humira, Skyrizi, Stelara, Entyvio, Remicade, Rinvoq). Returns FDA-approved indications stated conservatively, why plans deny that specific drug, what winning appeals argue, and the step-therapy exception framing â plus the published external-review record for the drug when the corpus has it. Accepts a brand or generic name.
読み取り専用
冪等
入力スキーマ
{'type': 'object', '$schema': 'http://json-schema.org/draft-07/schema#', 'required': ['drug'], 'properties': {'drug': {'type': 'string', 'maxLength': 80, 'minLength': 2, 'description': "Brand or generic drug name, e.g. 'Zepbound', 'ustekinumab'"}}, 'additionalProperties': False}
get_insurer_metrics
Get an insurer's verified CY2025 prior-authorization metrics (denial rate, appeal overturn rate, decision times) from its own CMS-0057-F disclosure, plus contract/plan-level rows where collected. Includes source URLs and scope notes.
読み取り専用
冪等
入力スキーマ
{'type': 'object', '$schema': 'http://json-schema.org/draft-07/schema#', 'required': ['slug'], 'properties': {'slug': {'type': 'string', 'description': "Insurer slug from list_insurers, e.g. 'unitedhealthcare'"}}, 'additionalProperties': False}
get_state_external_review
How a state's external review process works: filing deadline, regulator contact, and key facts. Verified detail currently covers 10 states (CA, TX, FL, NY, PA, IL, OH, GA, NC, MI); other states return the covered list.
読み取り専用
冪等
入力スキーマ
{'type': 'object', '$schema': 'http://json-schema.org/draft-07/schema#', 'required': ['state'], 'properties': {'state': {'type': 'string', 'maxLength': 2, 'minLength': 2, 'description': "Two-letter state code, e.g. 'ca', 'ny', 'fl'"}}, 'additionalProperties': False}
get_treatment_outcomes
External-review outcomes for a treatment: how often insurer denials of this treatment/drug/procedure were overturned by independent reviewers (42,749 published CA IMR decisions, 2001â2026). Accepts a category slug (e.g. 'pharmacy') or specific treatment slug (e.g. 'zepbound', 'speech-therapy').
読み取り専用
冪等
入力スキーマ
{'type': 'object', '$schema': 'http://json-schema.org/draft-07/schema#', 'required': ['slug'], 'properties': {'slug': {'type': 'string', 'description': "Treatment slug, e.g. 'zepbound', 'pharmacy', 'speech-therapy'. Use search_outcomes to find slugs."}}, 'additionalProperties': False}
list_insurers
List tracked U.S. health insurers with whether verified CMS-0057-F prior-authorization metrics are available for each.
読み取り専用
冪等
入力スキーマ
{'type': 'object', '$schema': 'http://json-schema.org/draft-07/schema#', 'properties': {}}
rank_denial_rates
Insurer prior-authorization denial rates (CY2025), ranked only within compatible reporting cohorts. Each row includes its cohort, rank within that cohort, exact source scope, calculation method, and source link. Never compare ranks across cohorts.
読み取り専用
冪等
入力スキーマ
{'type': 'object', '$schema': 'http://json-schema.org/draft-07/schema#', 'properties': {}}
search_outcomes
Search treatments (categories + specific drugs/procedures) and conditions by name. Returns slugs for get_treatment_outcomes / get_condition_outcomes plus headline overturn rates.
読み取り専用
冪等
入力スキーマ
{'type': 'object', '$schema': 'http://json-schema.org/draft-07/schema#', 'required': ['query'], 'properties': {'limit': {'type': 'integer', 'maximum': 50, 'minimum': 1, 'description': 'Max results per type (default 10)'}, 'query': {'type': 'string', 'minLength': 2, 'description': "Search text, e.g. 'wegovy', 'back pain', 'imaging'"}}, 'additionalProperties': False}
履歴
最近のツール変更
追加
get_state_external_review
2026年9月17日12:34
追加
get_drug_playbook
2026年9月17日12:34
追加
get_appeal_rights
2026年9月17日12:34
追加
search_outcomes
2026年9月17日12:34
追加
get_condition_outcomes
2026年9月17日12:34
追加
get_treatment_outcomes
2026年9月17日12:34
追加
rank_denial_rates
2026年9月17日12:34
追加
get_insurer_metrics
2026年9月17日12:34
追加
list_insurers
2026年9月17日12:34
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