{ "name": "Claim Denial Triage + Appeal Draft", "nodes": [ { "parameters": { "rule": { "interval": [{ "field": "cronExpression", "expression": "0 7 * * 1-5" }] } }, "id": "c3000000-0000-4000-8000-000000000001", "name": "Weekday mornings at 07:00", "type": "n8n-nodes-base.scheduleTrigger", "typeVersion": 1.2, "position": [-680, 0] }, { "parameters": { "url": "={{ $env.BILLING_BASE_URL }}/denials?since={{ $now.minus(1, 'days').toISODate() }}", "authentication": "genericCredentialType", "genericAuthType": "httpHeaderAuth", "options": {} }, "id": "c3000000-0000-4000-8000-000000000002", "name": "Fetch new denials", "type": "n8n-nodes-base.httpRequest", "typeVersion": 4.2, "position": [-460, 0], "notesInFlow": true, "notes": "From your clearinghouse or 835 remittance feed. Expected fields: claimId, patientRef, payer, cptCodes, icdCodes, chargeAmount, carcCode, rarcCode, denialText, serviceDate." }, { "parameters": { "jsCode": "// Classifies each denial by CARC code into the category that decides what happens next.\n// Rule-based on purpose: categorisation drives money, so it must be explainable.\n\nconst CATEGORIES = {\n eligibility: ['26','27','31','32','200','201'],\n registration: ['16','140','164','206'],\n authorization:['15','197','198','199'],\n coding: ['4','11','107','181','182','236'],\n bundling: ['97','234','B15'],\n timely: ['29'],\n duplicate: ['18'],\n medicalNecessity: ['50','55','56','167'],\n nonCovered: ['96','204','A1'],\n};\n\n// Appealing these rarely pays for the staff time it costs.\nconst LOW_YIELD = new Set(['duplicate', 'timely', 'nonCovered']);\n\nconst APPEAL_FLOOR = Number($env.APPEAL_FLOOR_USD || 25);\n\nreturn $input.all().map(item => {\n const d = item.json;\n const carc = String(d.carcCode || '').trim();\n\n let category = 'other';\n for (const [name, codes] of Object.entries(CATEGORIES)) {\n if (codes.includes(carc)) { category = name; break; }\n }\n\n const amount = Number(d.chargeAmount || 0);\n const preventable = ['eligibility', 'registration', 'coding', 'authorization'].includes(category);\n const worthAppealing = !LOW_YIELD.has(category) && amount >= APPEAL_FLOOR;\n\n return {\n json: {\n ...d,\n category,\n preventable,\n worthAppealing,\n priority: amount >= 500 ? 'high' : amount >= 150 ? 'medium' : 'low',\n },\n };\n});" }, "id": "c3000000-0000-4000-8000-000000000003", "name": "Categorise the denial", "type": "n8n-nodes-base.code", "typeVersion": 2, "position": [-240, 0] }, { "parameters": { "conditions": { "options": { "caseSensitive": true, "leftValue": "", "typeValidation": "strict", "version": 2 }, "conditions": [ { "id": "cond-worth-appealing", "leftValue": "={{ $json.worthAppealing }}", "rightValue": true, "operator": { "type": "boolean", "operation": "true", "singleValue": true } } ], "combinator": "and" }, "options": {} }, "id": "c3000000-0000-4000-8000-000000000004", "name": "Worth appealing?", "type": "n8n-nodes-base.if", "typeVersion": 2.2, "position": [-20, 0] }, { "parameters": { "method": "POST", "url": "https://api.anthropic.com/v1/messages", "sendHeaders": true, "headerParameters": { "parameters": [ { "name": "x-api-key", "value": "={{ $env.ANTHROPIC_API_KEY }}" }, { "name": "anthropic-version", "value": "2023-06-01" }, { "name": "content-type", "value": "application/json" } ] }, "sendBody": true, "specifyBody": "json", "jsonBody": "={{ JSON.stringify({\n model: 'claude-sonnet-5',\n max_tokens: 1200,\n system: 'You draft appeal letters for a US medical billing team. Write only from the facts supplied — never invent clinical details, dates, or policy citations. If a required fact is missing, write [MISSING: what is needed] inline so a human can fill it. Output the letter only, no preamble. A certified coder reviews every letter before it is sent.',\n messages: [{\n role: 'user',\n content: 'Draft a first-level appeal letter for this denial.\\n\\n' +\n 'Payer: ' + $json.payer + '\\n' +\n 'Claim ID: ' + $json.claimId + '\\n' +\n 'Date of service: ' + $json.serviceDate + '\\n' +\n 'CPT codes: ' + JSON.stringify($json.cptCodes) + '\\n' +\n 'ICD-10 codes: ' + JSON.stringify($json.icdCodes) + '\\n' +\n 'Billed amount: $' + $json.chargeAmount + '\\n' +\n 'Denial code: ' + $json.carcCode + ' / ' + ($json.rarcCode || 'n/a') + '\\n' +\n 'Denial reason given: ' + $json.denialText + '\\n' +\n 'Our category: ' + $json.category\n }]\n}) }}", "options": {} }, "id": "c3000000-0000-4000-8000-000000000005", "name": "Draft the appeal letter", "type": "n8n-nodes-base.httpRequest", "typeVersion": 4.2, "position": [220, -100], "notesInFlow": true, "notes": "Send de-identified claim data where your workflow allows it. The draft is always reviewed by a human before submission." }, { "parameters": { "jsCode": "const claim = $('Categorise the denial').item.json;\nconst response = $input.first().json;\nconst letter = response?.content?.[0]?.text || '[Draft failed — write manually]';\n\nconst needsInfo = /\\[MISSING:/i.test(letter);\n\nreturn [{\n json: {\n claimId: claim.claimId,\n payer: claim.payer,\n amount: claim.chargeAmount,\n category: claim.category,\n priority: claim.priority,\n needsInfo,\n letter,\n },\n}];" }, "id": "c3000000-0000-4000-8000-000000000006", "name": "Package for review", "type": "n8n-nodes-base.code", "typeVersion": 2, "position": [460, -100] }, { "parameters": { "sendTo": "={{ $env.BILLING_TEAM_EMAIL }}", "subject": "=[{{ $json.priority.toUpperCase() }}] Appeal draft ready — claim {{ $json.claimId }} ({{ $json.payer }}, ${{ $json.amount }})", "message": "=Category: {{ $json.category }}\nAmount: ${{ $json.amount }}\n{{ $json.needsInfo ? 'ACTION NEEDED: the draft contains [MISSING] markers — fill these before sending.' : 'Draft is complete pending your review.' }}\n\n--- DRAFT (review before sending) ---\n\n{{ $json.letter }}", "options": {} }, "id": "c3000000-0000-4000-8000-000000000007", "name": "Send draft to a human", "type": "n8n-nodes-base.gmail", "typeVersion": 2.1, "position": [700, -100], "webhookId": "c3000000-0000-4000-8000-000000000007", "notesInFlow": true, "notes": "Nothing is submitted automatically. A biller reviews, edits, and sends." }, { "parameters": { "operation": "append", "documentId": { "__rl": true, "value": "={{ $env.DENIAL_LOG_SHEET_ID }}", "mode": "id" }, "sheetName": { "__rl": true, "value": "Denials", "mode": "name" }, "columns": { "mappingMode": "defineBelow", "value": { "Date": "={{ $now.toISODate() }}", "Claim": "={{ $json.claimId }}", "Payer": "={{ $json.payer }}", "CARC": "={{ $json.carcCode }}", "Category": "={{ $json.category }}", "Preventable": "={{ $json.preventable ? 'Yes' : 'No' }}", "Amount": "={{ $json.chargeAmount }}", "Appealing": "={{ $json.worthAppealing ? 'Yes' : 'No' }}" } }, "options": {} }, "id": "c3000000-0000-4000-8000-000000000008", "name": "Log every denial", "type": "n8n-nodes-base.googleSheets", "typeVersion": 4.5, "position": [220, 140], "notesInFlow": true, "notes": "The real prize. After a month this sheet tells you which five payer rules cause most of your denials — that is where prevention work pays." } ], "connections": { "Weekday mornings at 07:00": { "main": [[{ "node": "Fetch new denials", "type": "main", "index": 0 }]] }, "Fetch new denials": { "main": [[{ "node": "Categorise the denial", "type": "main", "index": 0 }]] }, "Categorise the denial": { "main": [ [ { "node": "Worth appealing?", "type": "main", "index": 0 }, { "node": "Log every denial", "type": "main", "index": 0 } ] ] }, "Worth appealing?": { "main": [[{ "node": "Draft the appeal letter", "type": "main", "index": 0 }], []] }, "Draft the appeal letter": { "main": [[{ "node": "Package for review", "type": "main", "index": 0 }]] }, "Package for review": { "main": [[{ "node": "Send draft to a human", "type": "main", "index": 0 }]] } }, "pinData": {}, "settings": { "executionOrder": "v1" }, "tags": [{ "name": "healthcare" }, { "name": "revenue cycle" }] }