Instruction modules that compose your agent

Payer-side appeal processing with regulatory deadline tracking, determination letter generation, overturn analysis, and root cause remediation. Activate for member grievance, ERISA timeline, overturn analysis, IRE, or payer appeal processing.

PI audit management with provider selection, audit universe definition, extrapolation methodology, and overpayment calculation. Activate for PI audit, provider audit selection, audit universe, or extrapolation methodology.

Core agent/digital worker generation rules — single-page document processing workflow (Next.js + FastAPI)

Core multi-page app generation rules — App Router routes, shared navigation, CRUD patterns (Next.js + FastAPI)

OIG Work Plan mapping, RAC/MAC/CERT focus monitoring, physician billing outlier analysis, FCA exposure quantification, and regulatory change tracking. Activate for billing compliance, OIG Work Plan, RAC audit, FCA exposure, or physician billing outlier analysis.

PenguinAI design system: colors, gradients, glass morphism, Inter font, sidebar layout, Heroicons

CAHPS survey driver analysis with operational correlation, demographic segmentation, root cause mapping, and improvement priority modeling. Activate for CAHPS, member experience, patient satisfaction survey, or CAHPS driver analysis.

Discharge document compilation, three-list medication reconciliation, readmission risk stratification, post-discharge outreach scripting, document transmission tracking, and TCM billing support. Activate for care transition documents, discharge summary, medication reconciliation, post-discharge outreach, or TCM billing.

Cash-pay pricing strategy with cost analysis, 5-pillar framework, DPC membership design, competitor benchmarking, and fee schedule generation. Activate when user mentions cash-pay pricing, self-pay rates, DPC pricing, concierge pricing, fee schedule, cost-per-service, pricing strategy, or membership pricing.

Charge-to-documentation reconciliation, missed charge identification, CDM maintenance, charge lag tracking, and provider charge capture scorecards. Activate for charge capture, charge reconciliation, CDM maintenance, charge leakage, or missed charges.

Schedule-to-charge reconciliation, CDM validation, department-specific rules, missed charge scanning, anomaly detection, and charge lag monitoring. Activate for charge validation, charge completeness, CDM validation, missed charge detection, or pre-billing charge review.

Chart audit pipeline comparing submitted codes against documentation to find overcoding, undercoding, and compliance issues. Activate when user mentions chart audit, coding compliance, coding accuracy, overcoding, undercoding, or audit review.

Perplexity-style inline citations with expandable source references. Activate when the app needs AI-generated summaries, synthesis, narrative text with source attribution, chart summarization, clinical note synthesis, medical record review, or care gap analysis with cited sources.

Claims operations management with inventory monitoring, TAT tracking, auto-adjudication optimization, staffing allocation, and performance dashboards. Activate for claims operations, claims inventory, claims backlog, TAT monitoring, or auto-adjudication rate.

Payment accuracy auditing with statistical sampling, error classification, root cause analysis, inter-auditor calibration, and corrective action tracking. Activate for payment accuracy, claims QA audit, examiner accuracy, or financial accuracy rate.

CMS-1500 pre-submission claim scrubbing with 5 rule categories, NCCI bundling checks, and governance dashboard. Activate when user mentions CMS-1500, claim scrubbing, claim validation, pre-submission, NCCI bundling, or claim editing.

EDI 837/835 pipeline tracking, clearinghouse rejection monitoring, timely filing management, secondary claim generation, and payer connectivity health. Activate for claims submission pipeline, clearinghouse monitoring, EDI tracking, claim rejection, or timely filing.

UM clinical criteria matching with InterQual/MCG guideline alignment, clinical evidence extraction, and determination support. Activate for clinical criteria matching, UM review, medical necessity criteria, or utilization management.

Clinical denial evidence assembly, InterQual/MCG criteria matching, peer-to-peer preparation, appeal merit assessment, and upstream prevention recommendations. Activate for clinical denial review, medical necessity denial, level-of-care downgrade, peer-to-peer preparation, or InterQual/MCG criteria matching.

CDI pipeline for identifying documentation gaps, missing specificity, and generating physician query templates. Activate when user mentions CDI, clinical documentation improvement, documentation gaps, physician queries, documentation quality, or query generation.

PI clinical review with DRG validation, level-of-service review, clinical documentation analysis, and determination support. Activate for PI clinical review, DRG validation, level-of-service review, or payment integrity clinical audit.

COB and subrogation opportunity identification with other-party-liability detection, savings calculation, and recovery tracking. Activate for COB, coordination of benefits, subrogation, or third-party liability.

Credentialing and peer review committee packet generation with provider profile assembly, flag summaries, and presentation materials. Activate for committee packet, credentialing committee, or peer review committee.

Payer-specific criteria matching (InterQual, MCG), daily census review automation, continued stay authorization preparation, level-of-care analysis, and Two-Midnight Rule compliance. Activate for concurrent review, continued stay review, InterQual criteria, Milliman criteria, or inpatient utilization review.

Contract term financial modeling, rate change impact analysis, scenario simulation, revenue projection, contract comparison, and portfolio optimization. Activate for contract financial modeling, rate change impact, contract term simulation, or contract comparison.

Contract obligation monitoring, renewal deadline tracking, term compliance validation, contract expiration management, and compliance reporting. Activate for contract compliance, contract lifecycle, contract obligation monitoring, or contract renewal deadlines.

Provider contract rate modeling with fee schedule comparison, reimbursement scenario analysis, and negotiation support. Activate for contract modeling, provider rates, fee schedule modeling, or reimbursement analysis.

Automated payment-to-contract comparison, underpayment detection, dispute documentation generation, and systemic underpayment pattern analysis. Activate for underpayment recovery, contract variance, payment-to-contract comparison, or fee schedule variance.

Provider credentialing automation with CAQH integration, primary source verification, timeline tracking, and committee preparation. Activate for credentialing, provider enrollment, CAQH, or primary source verification.

Provider data reconciliation across systems with NPI validation, directory accuracy monitoring, and discrepancy resolution. Activate for provider data reconciliation, directory accuracy, or cross-system data matching.

Executive dashboards with metric cards, charts, and drill-down. Activate when the app needs dashboards, metrics, analytics, KPIs, reporting, productivity tracking, turnaround times, financial impact summaries, or any data visualization with drill-down.

Sortable, filterable, paginated data tables with bulk actions and export. Activate when the app needs lists, tables, work queues, rosters, directories, audit logs, or any searchable/filterable tabular data display.

Delegated entity oversight with NCQA delegation standards, audit scheduling, performance monitoring, and corrective action tracking. Activate for delegation oversight, delegated entity audit, or delegation performance monitoring.

Denial root cause tracing, statistical trend analysis, prevention initiative ROI modeling, payer behavior change detection, and cross-functional action plans. Activate for denial prevention, denial root cause analysis, avoidable denials, denial trending, or prevention initiative ROI.

Denial classification by CARC/RARC codes into 12 categories, DOPS priority scoring, appealability determination, and queue routing. Activate when user mentions denial classification, CARC, RARC, denial triage, appealability, DOPS, or denial queue.

Denial pipeline visibility, financial performance analytics, predictive volume and recovery modeling, complexity-adjusted team performance, and resource allocation optimization. Activate for denials operations dashboard, denial pipeline, denial recovery forecasting, denial team performance, or denial function ROI.

Discharge readiness assessment, post-acute facility matching (SNF/IRF/LTAC/home health), readmission risk scoring (LACE/HOSPITAL), avoidable days monitoring, and HRRP penalty prevention. Activate for discharge planning, discharge readiness, post-acute placement, readmission risk, or avoidable days.

EDI transaction error diagnostics with 837/835 parsing, rejection analysis, HIPAA compliance checking, and error pattern detection. Activate for EDI errors, EDI diagnostics, 837/835 errors, or HIPAA transaction troubleshooting.

Payment integrity edit lifecycle management with edit performance tracking, ROI analysis, false positive tuning, and pre/post-pay edit optimization. Activate for PI edits, claim edit lifecycle, edit performance, or edit ROI.

Fee schedule cascade validation, fee schedule loading and comparison, automated underpayment identification from fee schedule variances, and fee schedule maintenance. Activate for fee schedule validation, fee schedule cascade, fee schedule loading, or automated underpayment detection.

Registration denial root cause analysis, denial-to-registration tracing, SPC trend analysis, registrar performance profiling, and corrective action tracking. Activate for front-end denial prevention, registration denial root cause, eligibility denial tracing, or registrar performance.

Fraud, waste, and abuse investigation with case management, aberrant billing pattern detection, evidence assembly, and regulatory reporting. Activate for FWA, fraud investigation, SIU, aberrant billing, or whistleblower tips.

HEDIS quality measure gap identification with 2-pass LLM pipeline (clinical history extraction + gap identification), 30 measures across 4 categories, severity ranking, and compliance tracking. Activate when user mentions HEDIS, care gaps, gaps in care, preventive screening, quality measures, immunization tracking, behavioral health follow-ups, or compliance rate.

HCC prospective coding pipeline for real-time encounter coding. Only codes conditions actively addressed in the current encounter. Activate when user mentions prospective HCC coding, real-time encounter coding, point-of-care HCC capture, or prospective risk adjustment.

HCC retrospective coding pipeline with MEAT evidence extraction, governance rules, and combination coding. Only activate when the user explicitly mentions HCC, risk adjustment, RAF scores, retrospective chart review, or hierarchical condition categories. Do NOT activate for generic 'medical coding' requests.

HEDIS chart chase workflow with CSV roster import, retrieval tracking, single-pass AI substantiation, and closure rate dashboards. Activate when user mentions chart chase, chart retrieval, medical record retrieval, HEDIS audit season, chart substantiation, measure substantiation, closure rates, or record request tracking.

HEDIS measure specification parsing, logic validation, value set verification, test case execution, and audit readiness scoring. Activate for measure logic validation, value set verification, HEDIS specification, or measure audit readiness.

Unified DNFB management, intelligent chart routing, coding workforce management, vendor scorecards, volume forecasting, and quality-productivity monitoring. Activate for HIM operations, DNFB management, chart routing, coding workforce, or vendor coding performance.

OASIS QA review, item-by-item validation with CMS citations, systemic error pattern analysis, operations dashboard, visit utilization optimization, quality measure decomposition, and staff performance scorecards. Activate for home health operations, OASIS QA, home health quality measures, or home health survey readiness.

PDGM diagnosis extraction, ICD-10-CM mapping, primary diagnosis optimization, NOA timeliness monitoring, LUPA risk detection, billing compliance validation, and payment variance analysis. Activate for home health coding, PDGM coding, home health billing, NOA timeliness, or LUPA monitoring.

ICD-10 prospective coding pipeline with MEAT evidence, governance rules, and combination coding. Activate for medical coding, ICD coding, ICD-10, encounter coding, chart completion, real-time coding assist, or prospective coding.

Expected recovery value scoring, multi-payer 277 claim status consolidation, action recommendations, write-off analysis, and specialist performance tracking. Activate for AR prioritization, accounts receivable work queue, expected recovery scoring, or claim status tracking.

OCR-powered document classification, EMPI patient matching, auto-indexing, duplicate detection, ROI authorization validation, and pre-encounter record availability. Activate for document intake, medical record indexing, document classification, patient matching, or ROI processing.

Member outreach prioritization with composite scoring, channel optimization, barrier-specific messaging, TCPA compliance, and campaign tracking. Activate for member outreach, outreach prioritization, engagement scoring, or outreach campaign optimization.

Drag-and-drop kanban columns representing workflow stages. Activate when the app needs workflow tracking, status pipelines, task boards, case management, PA tracking boards, appeals pipelines, or any drag-and-drop stage-based workflow.

Batch eligibility verification across payers with benefit standardization, COB determination, PA requirement identification, and patient responsibility estimation. Activate for benefit verification, eligibility batch, insurance verification, COB determination, or coverage check.

Multi-step forms with validation, progress indicator, and review step. Activate when the app needs multi-step forms, intake workflows, submission forms, enrollment forms, PA submissions, appeal letters, credentialing forms, or any wizard-style data entry.

Market rate benchmarking, negotiation package assembly, leverage analysis, payer negotiation preparation, and contract renewal strategy. Activate for negotiation intelligence, negotiation package, market rate benchmarking, payer negotiation, or contract renewal preparation.

Network adequacy assessment with time/distance analysis, appointment availability measurement, CMS compliance checking, and gap identification. Activate for network adequacy, provider network assessment, or CMS network requirements.

OASIS pre-population from clinical notes, M-item consistency validation, functional/cognitive score cross-checking, QAPI survey readiness, ADR response assembly, and error pattern tracking. Activate for OASIS assessment, OASIS pre-population, M-item validation, QAPI survey readiness, or ADR response.

OCR and LLM API endpoint details and response shapes

Orthopedic operative-report coding: CPT procedure coding with NCCI/MUE/MPFS surgical bundling, ICD-10 diagnosis coding, LCD coverage / medical-necessity, and chart audit of human-assigned codes. Activate for orthopedic coding, ortho surgery coding, CPT procedure coding, surgical bundling, operative report coding, MSK coding, medical necessity / coverage, or coding audit.

Overpayment pattern discovery with data mining, anomaly detection, statistical analysis, and concept generation. Activate for overpayment patterns, data mining for PI, or payment anomaly detection.

PA chart summarization pipeline: upload a clinical document, OCR it, and get a structured summary with diagnoses, medications, procedures, clinical timeline, PA brief, governance checks, and bounding boxes. Activate when user mentions chart summarization, clinical chart summary, PA chart review, medical record summary, or chart abstraction.

Patient AR segmentation and forecasting, propensity-to-pay modeling, bad debt reserve estimation, collection agency comparison, waterfall analysis, and executive collections reporting. Activate for patient AR analytics, collections command center, AR segmentation, bad debt forecasting, or collections performance dashboard.

Propensity-driven outreach optimization, patient billing communication, multi-program financial assistance screening, payment plan lifecycle management, and FDCPA/501(r) compliance. Activate for patient collections, self-pay collections, financial assistance screening, payment plan management, or patient billing communication.

Pre-service cost estimation, financial assistance screening (charity care, Medicaid, foundation programs), payment plan recommendations, 501(r) compliance, and price transparency. Activate for patient financial clearance, cost estimation, financial assistance, charity care, or price transparency.

Escalation package assembly, JOC meeting preparation, payer commitment tracking, and financial impact quantification for payer issues. Activate for payer escalation, JOC meeting preparation, payer commitment tracking, or escalation package building.

Payer performance ranking, operational behavior analytics, payment trend analysis, denial pattern monitoring, and payer comparison dashboards. Activate for payer scorecard, payer behavior analytics, payer performance ranking, or payer comparison.

Pended/suspended claim resolution with pend reason analysis, examiner workbench, resolution workflows, and productivity tracking. Activate for pended claims, suspended claims, claim resolution queue, or examiner workbench.

Payment integrity program optimization with ROI analysis, cost avoidance vs recovery metrics, vendor performance, and strategic planning. Activate for PI program performance, payment integrity ROI, or PI dashboard.

Benefit plan configuration validation with test case generation, regression testing, and configuration audit. Activate for plan configuration, benefit validation, benefit table testing, or configuration audit.

Practice operations optimization with patient flow analysis, scheduling model comparison, no-show management, door-to-door benchmarking, 20+ KPI scoring, Lean waste identification, and bottleneck diagnosis. Activate when user mentions practice operations, patient flow, scheduling optimization, no-show management, room utilization, door-to-door time, operational bottlenecks, Lean healthcare, wait times, throughput, or operations KPIs.

Dynamic pre-op checklist generation, multi-system completion tracking, escalating alert system, cancellation risk prediction, ACC/AHA cardiac guidelines, and medication management protocols. Activate for pre-surgical readiness, pre-op checklist, surgical clearance, or case cancellation prevention.

Payer-side PA intake processing with EDI-278 handling, UM intake queue, auto-routing, and turnaround tracking. Activate for payer PA intake, EDI-278, UM intake coordinator, or payer-side authorization processing.

Prior authorization workflow including clinical extraction, medical necessity determination, PA form generation, status tracking, peer-to-peer prep, and denial-to-appeal handoff. Activate when user mentions prior auth, pre-authorization, pre-cert, PA submission, medical necessity, authorization request, peer to peer, auth tracking, or coverage determination.

Medication adherence risk identification with PDC calculation, fill pattern analysis, projected breach dates, risk scoring, and intervention matching. Activate for PDC, medication adherence, pharmacy adherence risk, or proportion of days covered.

Provider inquiry and dispute resolution with case tracking, root cause analysis, and resolution workflows. Activate for provider inquiry, provider dispute, provider complaint, or provider relations.

Provider-specific HCC capture performance scorecards, peer benchmarking, suspect condition lists with clinical evidence, targeted documentation education, compliant physician queries, and engagement tracking. Activate for provider education, physician scorecards, HCC capture reporting, suspect condition lists, or documentation improvement.

Contract rate engine supporting multiple reimbursement methodologies, payment-to-contract comparison, underpayment recovery queue, fee schedule validation, and contract financial scenario modeling. Activate for provider-side contract rate modeling, reimbursement comparison, or fee schedule load validation.

Quality improvement intervention design with root cause analysis, PDSA cycle construction, intervention scoring, and Star Rating impact modeling. Activate for QI intervention, quality improvement program, PDSA cycle, or care gap intervention design.

Unified executive dashboard across all risk adjustment and VBC programs, with program ROI analysis, VBC contract portfolio tracking, CMS model change impact modeling, strategic financial scenarios, provider engagement analytics, and board-ready reporting. Activate for RA/VBC program dashboard, unified program performance, executive RA reporting, or VBC portfolio analytics.

Internal RAF score calculation, CMS score reconciliation, revenue forecasting under multiple scenarios, V28 transition modeling, encounter submission tracking, and member attribution validation. Activate for RAF reconciliation, risk adjustment revenue forecasting, encounter submission tracking, V28 modeling, or member attribution.

Overpayment recovery lifecycle with demand letter generation, provider offset management, recovery pipeline tracking, and aging analysis. Activate for PI recovery, overpayment recovery, demand letter, or recoupment.

Referral validation, payer-specific requirements, in-network provider matching, leakage prevention, auth cross-check, completion tracking, and leakage analytics. Activate for referral management, referral tracking, referral leakage, network leakage, or referral lifecycle.

ERA 835 processing, enhanced auto-posting, payment-to-contract comparison, CARC/RARC analysis, underpayment alerts, recoupment validation, and credit balance management. Activate for remittance processing, ERA 835, auto-posting, payment posting, or credit balance management.

End-to-end RCM KPI monitoring, automated root cause decomposition, predictive cash flow modeling, payer behavior anomaly detection, and staff performance scoring. Activate for RCM command center, revenue cycle dashboard, end-to-end KPIs, cash flow forecasting, or executive RCM reporting.

Risk stratification with impactability scoring, care management panel optimization, patient engagement prediction, utilization driver analysis, SDOH barrier identification, ADT alerting, and care management ROI measurement. Activate for care management optimization, risk stratification, utilization reduction, SDOH, or care management ROI.

UI pattern for showing AI predictions/classifications with supporting evidence. Activate whenever the app involves AI/ML predictions, classifications, coding, scoring, or any output where the user needs to understand WHY the AI made a decision — e.g. medical coding, risk scoring, diagnosis suggestions, document analysis, NLP extraction. The core principle: every AI prediction must show its supporting evidence from the source document.

Staffing optimization with task-to-model mapping, FTE/VA/AI cost comparison, quadrant analysis, and ROI projections. Activate when user mentions staffing, workforce optimization, hiring decisions, FTE vs VA vs AI, staffing cost calculator, hybrid staffing, right-sizing staff, or automation ROI for staffing.

Star Rating strategy optimization with measure simulation, bubble measure identification, cost-effectiveness analysis, investment optimization, and QBP revenue projection. Activate for Star Rating, CMS Star, Star Rating optimization, QBP bonus, or bubble measures.

Supplemental data feed monitoring with ingestion tracking, validation rules, NCQA certification compliance, and rate lift analysis. Activate for supplemental data, data feed monitoring, NCQA data certification, or supplemental data pipeline.

Data-driven coder and physician training, annual code update analysis, individual education plans, coding scenario libraries, and training effectiveness measurement. Activate for coding education, coder training, coding competency, physician documentation education, or training effectiveness.

Multi-contract VBC performance tracking, total cost of care monitoring, quality gate attainment tracking, care gap worklists, settlement forecasting, and supplemental data capture. Activate for VBC contract monitoring, TCOC analysis, quality gate tracking, care gap closure, shared savings projection, or settlement forecasting.