DECISION_TREE.md

Decision tree, which template applies

A fast-reference flowchart-style document. Use this when you have a specific bill in hand and need to pick the right template quickly. The LLM follows the same logic in llm/workflow.md, but having a printable single-page reference is useful when the LLM is unavailable or when you want to sanity-check the model's recommendation.

Step 1, What kind of bill is it?

• Bill from a healthcare provider (hospital, doctor, lab, ambulance, durable medical equipment vendor) → Step 2.
• Letter from a debt collector that says "this is an attempt to collect a debt" → templates/letter_fdcpa_validation.md (if within 30 days of first contact).
• Denial letter from your insurance company (no provider bill yet, or the bill is paid pending appeal) → Step 3 (Insurance denial).
• Hospital lien notice (filed against your personal-injury settlement) → templates/letter_auto_med_pay.md Variant C.
• Insurance company demanding repayment of a paid claim (subrogation) → consult rules/15_auto_med_pay.md.

Step 2, Is the provider bill itemized?

• No, the bill is a summary statement only → templates/letter_itemization_request.md.
• Yes, proceed to Step 4.

Step 3, Insurance denial

Identify the plan type. This is the most important question in any insurance denial appeal.

• Employer-sponsored, self-funded ERISA (most large-employer plans) → templates/letter_insurance_appeal_erisa.md.
• Employer-sponsored, fully-insured → also use letter_insurance_appeal_erisa.md but the state insurance department complaint at templates/complaint_state_doi.md is more powerful here.
• Medicare (Part A/B/C/D) → templates/letter_medicare_appeal.md and rules/12_medicare_appeals.md.
• Medicaid / state managed care (e.g., TennCare) → templates/letter_medicaid_appeal.md.
• TRICARE → consult rules/18_tricare.md and contact a Beneficiary Counseling and Assistance Coordinator (BCAC).
• VA Community Care → consult rules/19_va_community_care.md and contact a VA Patient Advocate or Veterans Service Organization.
• Dental insurance → templates/letter_dental_dispute.md.
• Individual market ACA plan → use letter_insurance_appeal_erisa.md but adapt the legal citations (no ERISA, use ACA appeal rules in 45 CFR § 147.136).

Step 4, What's wrong with the bill?

Most bills have more than one issue. Pick the most leveraged dispute first:

4a, Did emergency care happen?

• Service was emergency, provider was out-of-network or facility was out-of-network → templates/letter_no_surprises_violation.md (federal No Surprises Act).
• You were denied emergency screening or stabilization or were inappropriately transferred → templates/complaint_emtala.md (federal EMTALA).

4b, Was the patient at an in-network facility but the bill is from an out-of-network ancillary?

(Anesthesiology, radiology, pathology, lab, hospitalist, intensivist, neonatology, assistant surgeon)

• Yes → templates/letter_no_surprises_violation.md (federal No Surprises Act).

4c, Is the bill for a ground ambulance?

• Yes, and the patient's state is on the protected list (CA, CO, DE, GA, IL, ME, MD, NY, OH, VT, WA) and the plan is not ERISA self-funded → templates/letter_ground_ambulance.md Variant A.
• Yes, but the state is not on the list or the plan is ERISA self-funded → templates/letter_ground_ambulance.md Variant B.

4d, Is the bill from an accident (motor vehicle, slip-and-fall, etc.)?

• Yes → consult rules/15_auto_med_pay.md. Force the correct payer order. Variant A demands med-pay/PIP. Variant B forces hospital to bill health insurance. Variant C challenges a hospital lien.

4e, Is the bill from a work-related injury?

• Yes, workers' comp claim accepted, but bill came to you directly → consult rules/16_workers_comp.md. Redirect to WC carrier; balance billing is prohibited.
• Yes, but workers' comp claim is contested or denied → file the WC appeal in state's WC system, run health insurance as the interim payer.

4f, Is the bill from a telehealth visit?

• Yes, and there's a coding or coverage issue → consult rules/20_telehealth.md. Most issues are POS code or modifier errors, or state telehealth-parity violations.

4g, Is the ER visit CPT severity-coded too high?

(99284 or 99285 for a short, low-complexity visit; 99214 or 99215 for a brief office visit)

• Yes → templates/letter_initial_dispute.md with CPT upcoding block. Cite the AMA 2023 E/M documentation requirements from references/cpt_codes_em.md.

4h, Is the bill price-gouging?

(Charge is significantly above Medicare allowable, hospital's posted cash price, or fair-market range from Turquoise Health / FAIR Health Consumer)

• Yes → templates/letter_initial_dispute.md with price-gouging block. Cite UCC § 2-305(2) (open price term, good faith).

4i, Is the bill for a service you didn't receive?

• Yes → templates/letter_initial_dispute.md with services-not-received block.

4j, Are there duplicate line items?

• Yes → templates/letter_initial_dispute.md with duplicate-charge block.

4k, Is the bill correctly coded but you cannot afford it?

For non-profit hospital bills (most US hospitals):

• → templates/letter_financial_assistance_application.md (IRS § 501(r) FAP application).
• Plus: screen at Dollar For for free help.

For for-profit hospitals or any other provider:

• → templates/letter_hardship_negotiation.md (hardship reduction anchored to Medicare allowable).

4l, Self-pay/uninsured patient + final bill more than $400 over Good Faith Estimate?

• → consult rules/11_ppdr_walkthrough.md and file Patient-Provider Dispute Resolution at the federal IDR portal.

4m, Hospital has not posted a compliant Hospital Price Transparency machine-readable file?

• → templates/complaint_cms_hpt.md (CMS complaint, parallel to your underlying dispute).

4n, Provider won't release your medical or billing records?

• → templates/complaint_hipaa_access.md (HHS Office for Civil Rights complaint).

Step 4a, If the bill is materially over Medicare and both gates are open

If you have both the EOB and an itemized bill, and your line items are billed at 1.5x or more of the Medicare allowable rate (run scripts/fetch_price_benchmarks.py to compute), the negotiated counter-offer is usually the strongest first move:

• → templates/letter_negotiation_counter_offer.md (UCC § 2-305 counter-offer with the line-item benchmark table built in; auto-anchored at 200% of Medicare).

Step 4b, If the encounter has 4+ separate providers

A hospital admission generating bills from facility + ER physician + radiology + anesthesia is one encounter. Apply the NSA ancillary-provider theory across the whole encounter, not bill-by-bill:

• → templates/encounter_combined_dispute.md (one letter addressing every provider; the kit auto-drafts this when the encounter clustering hits the 4-biller threshold).

Step 4c, If the bill is for an injury that should be billed elsewhere

For work-related injuries:

• → templates/letter_wc_carrier_redirect.md (workers'-comp carrier under the state WC anti-balance-billing statute).

For motor-vehicle accidents:

• → templates/letter_auto_med_pay.md (auto med-pay / PIP carrier).

The kit auto-detects these from sidecar keywords during drafting; they run alongside (not instead of) the regular dispute flow.

Step 4d, If the provider replied but didn't address the substance

A form letter, a new statement at the original balance, a "we reviewed the account" conclusion, or an invitation to call when you asked for writing are all non-responses:

• → templates/letter_dispute_reply.md (re-anchor with a 15-business-day final window, then escalate).

Step 4e, If a hospital lien has been filed against a tort recovery

• → templates/letter_challenge_hospital_lien.md (six grounds including bill-insurance-first, chargemaster vs allowed, made-whole doctrine, statutory cap).

Step 4f, If a plan is asserting subrogation against your recovery

• → templates/letter_subrogation_response.md (demand SPD, preserve made-whole and common-fund defenses, allocate between economic and non-economic damages).

Step 4g, If the debt has been reported to a credit bureau

• → templates/letter_credit_report_dispute_fcra.md (one letter per bureau plus the furnisher; eight grounds including federal CFPB rule and state bans).

Step 4h, If the plan is balance-billing on an NSA-protected service

• → templates/letter_request_insurer_initiate_idr.md (demand the plan initiate federal Independent Dispute Resolution; confirm cost-sharing fixed at in-network amount).

Step 4i, If you're uninsured and want the NSA self-pay path

• → templates/letter_good_faith_estimate_request.md before service or post-bill.
• → templates/letter_ppdr_initiate.md when the final bill exceeds the GFE by $400+.

Step 4j, If you want HIPAA medical records to verify what was actually delivered

• → templates/letter_records_request_hipaa.md (45 CFR § 164.524 right of access, 30-day statutory clock). Auto-drafted when the audit detector flags service_not_received_suspected.

Step 4k, If the plan administrator missed the 30-day plan-document request

• → templates/letter_erisa_502c_penalty.md ($110/day statutory penalty under § 502(c)(1), payable to you).

Step 5, After 30 days of no substantive response

If you sent an initial dispute letter (4g-4j above) and the provider has not responded substantively within 15-30 days:

• → templates/letter_30day_warning.md (CC state insurance department, state AG, BBB).

Step 6, After the 30-day warning expires

If the 30-day warning has been ignored:

• → templates/complaint_state_doi.md (file state DOI complaint; the kit also auto-drafts this alongside the main dispute letter, so you may already have a draft).
• → templates/small_claims_civil_warrant.md (county-agnostic civil-warrant skeleton you transcribe onto your county clerk's form). See rules/06_small_claims.md and examples/small_claims_walkthrough.md.
• → If the hospital is a non-profit and the conduct contradicts its Schedule H representations, templates/complaint_irs_form_13909.md in parallel.

Step 6a, If the dispute warrants attorney engagement

If the amount in controversy approaches the small-claims jurisdictional limit, an ERISA fiduciary claim is in play, the dispute involves a hospital lien blocking a tort settlement, or the kit's free flow has stopped producing results:

• → templates/attorney_intake_packet.md (two-page case summary with artifact index for an intake consult).

Step 7, If the debt has been overwhelming

If medical debt has put you in a position where no realistic repayment is possible:

• → consult rules/17_bankruptcy_and_medical_debt.md. Bankruptcy may be the right tool. Try the dispute, charity-care, and hardship paths first; bankruptcy is the last move, not the first.

Edge cases that don't fit the tree

• Multiple bills from one hospital encounter (hospital + ER physician group + radiologist + anesthesiologist), apply the tree to each separately. They often have different issues.
• An old bill that's been ignored for months, your state's statute of limitations matters. See your state pack.
• A bill while you're already in dispute, log it in the tracker and treat as continuation, not a new fight.
• A bill from a non-US provider, out of scope for this kit.
• A veterinary bill, out of scope.

When the LLM disagrees

If you walk through this tree and arrive at a different template than the LLM recommends, ask the LLM to explain its reasoning. Either the LLM is missing something specific to your case, or the tree is missing a nuance. Both are useful feedback; the latter goes in a GitHub issue.

Print this

This document is intentionally short. Print it. Keep a copy in the folder where you store your bills. The LLM is the day-to-day tool; this is the index.