Update SOP guidelines to explicitly require formal appeal letters

generate_sop_docs.py

@@ -0,0 +1,593 @@
+"""
+Generate synthetic SOP (Standard Operating Procedure) PDFs for each payer.
+Replaces old BCBS/Aetna/Medicare SOPs with synthetic payer names.
+Each SOP contains resolution workflows for CO-252 and CO-16 denial codes,
+with specific guidance for M127 remark code (missing medical records).
+
+The SOPs are structured to guide the RCA and Execution agents through:
+  RCA: Identify denial → Analyse EOB → Map to SOP steps
+  Execution: Retrieve docs → Submit to payer → Case summary (human review) → Update provider DB
+"""
+
+from reportlab.lib.pagesizes import letter
+from reportlab.lib.units import inch
+from reportlab.lib import colors
+from reportlab.pdfgen import canvas
+from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
+from reportlab.platypus import (
+    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
+    PageBreak, HRFlowable
+)
+from reportlab.lib.enums import TA_LEFT, TA_CENTER
+import os
+
+SOP_DIR = os.path.join(os.path.dirname(os.path.abspath(__file__)), "sop")
+
+# ═══════════════════════════════════════════════
+# Payer configurations (all synthetic)
+# ═══════════════════════════════════════════════
+PAYERS = {
+    "Summit_Health": {
+        "name": "Summit Health Insurance of Texas",
+        "short": "Summit Health",
+        "portal": "provider.summithealth.example",
+        "filing_deadline": "180 days from denial date",
+        "filename": "Summit_Health.pdf",
+    },
+    "Crestview_Health": {
+        "name": "Crestview Health Plans",
+        "short": "Crestview Health",
+        "portal": "provider.crestviewhealth.example",
+        "filing_deadline": "180 days from denial date",
+        "filename": "Crestview_Health.pdf",
+    },
+    "NationalCare": {
+        "name": "NationalCare",
+        "short": "NationalCare",
+        "portal": "portal.nationalcare.example",
+        "filing_deadline": "120 days from denial date",
+        "filename": "NationalCare.pdf",
+    },
+}
+
+
+def build_styles():
+    """Create reusable paragraph styles."""
+    styles = getSampleStyleSheet()
+
+    styles.add(ParagraphStyle(
+        name='SOPTitle',
+        parent=styles['Title'],
+        fontSize=18,
+        spaceAfter=6,
+        textColor=colors.HexColor('#1a1a2e'),
+    ))
+    styles.add(ParagraphStyle(
+        name='SOPSubtitle',
+        parent=styles['Heading2'],
+        fontSize=13,
+        spaceAfter=4,
+        textColor=colors.HexColor('#16213e'),
+    ))
+    styles.add(ParagraphStyle(
+        name='SOPHeading',
+        parent=styles['Heading2'],
+        fontSize=12,
+        spaceBefore=14,
+        spaceAfter=6,
+        textColor=colors.HexColor('#0f3460'),
+    ))
+    styles.add(ParagraphStyle(
+        name='SOPStepHeading',
+        parent=styles['Heading3'],
+        fontSize=11,
+        spaceBefore=10,
+        spaceAfter=4,
+        textColor=colors.HexColor('#1a1a2e'),
+        leftIndent=10,
+    ))
+    styles.add(ParagraphStyle(
+        name='SOPBody',
+        parent=styles['Normal'],
+        fontSize=9.5,
+        leading=13,
+        spaceAfter=4,
+    ))
+    styles.add(ParagraphStyle(
+        name='SOPBullet',
+        parent=styles['Normal'],
+        fontSize=9.5,
+        leading=13,
+        leftIndent=24,
+        spaceAfter=2,
+        bulletIndent=12,
+    ))
+    styles.add(ParagraphStyle(
+        name='SOPSubBullet',
+        parent=styles['Normal'],
+        fontSize=9,
+        leading=12,
+        leftIndent=40,
+        spaceAfter=2,
+        bulletIndent=28,
+    ))
+    styles.add(ParagraphStyle(
+        name='SOPMeta',
+        parent=styles['Normal'],
+        fontSize=9,
+        leading=12,
+        textColor=colors.HexColor('#444444'),
+    ))
+    return styles
+
+
+def add_metadata_table(story, payer, denial_code, title, styles):
+    """Add the header metadata table for an SOP section."""
+    story.append(Paragraph(payer["short"], styles['SOPTitle']))
+    story.append(Paragraph(title, styles['SOPSubtitle']))
+    story.append(Spacer(1, 8))
+
+    meta_data = [
+        ["Payer", payer["name"], "Version", "2.0"],
+        ["Effective", "January 2025", "Department", "Revenue Cycle Management"],
+        ["Portal", payer["portal"], "Filing Deadline", payer["filing_deadline"]],
+    ]
+    meta_table = Table(meta_data, colWidths=[70, 190, 90, 170])
+    meta_table.setStyle(TableStyle([
+        ('FONTNAME', (0, 0), (-1, -1), 'Helvetica'),
+        ('FONTSIZE', (0, 0), (-1, -1), 9),
+        ('FONTNAME', (0, 0), (0, -1), 'Helvetica-Bold'),
+        ('FONTNAME', (2, 0), (2, -1), 'Helvetica-Bold'),
+        ('TEXTCOLOR', (0, 0), (0, -1), colors.HexColor('#0f3460')),
+        ('TEXTCOLOR', (2, 0), (2, -1), colors.HexColor('#0f3460')),
+        ('BACKGROUND', (0, 0), (-1, -1), colors.HexColor('#f0f4f8')),
+        ('GRID', (0, 0), (-1, -1), 0.5, colors.HexColor('#cccccc')),
+        ('VALIGN', (0, 0), (-1, -1), 'MIDDLE'),
+        ('TOPPADDING', (0, 0), (-1, -1), 4),
+        ('BOTTOMPADDING', (0, 0), (-1, -1), 4),
+        ('LEFTPADDING', (0, 0), (-1, -1), 6),
+    ]))
+    story.append(meta_table)
+    story.append(Spacer(1, 12))
+
+
+def add_co252_section(story, payer, styles):
+    """Add the CO-252 denial resolution SOP section."""
+
+    add_metadata_table(
+        story, payer, "CO-252",
+        "CO-252 Denial Resolution — Additional Documentation Required",
+        styles
+    )
+
+    # ── Overview ──
+    story.append(Paragraph("Overview", styles['SOPHeading']))
+    story.append(Paragraph(
+        "CO-252 is a Claim Adjustment Reason Code (CARC) indicating that additional documentation or "
+        "attachments are required by the payer to process or adjudicate the claim. The claim cannot be "
+        "processed until the missing supporting information is submitted.",
+        styles['SOPBody']
+    ))
+    story.append(Paragraph(
+        "CO-252 denials are <b>NOT</b> a medical necessity denial — they are a <b>documentation deficiency</b>. "
+        "The service may be covered, but the claim cannot be adjudicated without the required supporting documentation.",
+        styles['SOPBody']
+    ))
+    story.append(Spacer(1, 4))
+
+    # ── Remark Codes ──
+    story.append(Paragraph("Associated Remark Codes", styles['SOPHeading']))
+    story.append(Paragraph(
+        "CO-252 denials are always accompanied by one or more Remittance Advice Remark Codes (RARCs) "
+        "that specify exactly what documentation is missing. Common remark codes include:",
+        styles['SOPBody']
+    ))
+
+    remark_data = [
+        ["Remark Code", "Description", "Required Action"],
+        ["M127", "Missing patient medical record for this service",
+         "Retrieve and submit the operative report, chart notes, or clinical documentation for the date of service"],
+        ["M15", "Missing/incomplete/invalid clinical documentation",
+         "Obtain complete clinical notes from the provider and resubmit"],
+        ["MA130", "Paper claim/attachment may be needed",
+         "Submit documentation via payer portal or as paper attachment"],
+        ["N479", "Missing operative report",
+         "Retrieve operative report from the surgical facility and submit with appeal"],
+        ["N519", "Missing pathology report",
+         "Retrieve pathology report and submit with the claim resubmission"],
+    ]
+    remark_table = Table(remark_data, colWidths=[70, 200, 250])
+    remark_table.setStyle(TableStyle([
+        ('FONTNAME', (0, 0), (-1, 0), 'Helvetica-Bold'),
+        ('FONTSIZE', (0, 0), (-1, -1), 8),
+        ('BACKGROUND', (0, 0), (-1, 0), colors.HexColor('#1a1a2e')),
+        ('TEXTCOLOR', (0, 0), (-1, 0), colors.white),
+        ('BACKGROUND', (0, 1), (-1, -1), colors.HexColor('#fafafa')),
+        ('GRID', (0, 0), (-1, -1), 0.5, colors.HexColor('#cccccc')),
+        ('VALIGN', (0, 0), (-1, -1), 'TOP'),
+        ('TOPPADDING', (0, 0), (-1, -1), 4),
+        ('BOTTOMPADDING', (0, 0), (-1, -1), 4),
+        ('LEFTPADDING', (0, 0), (-1, -1), 4),
+    ]))
+    story.append(remark_table)
+    story.append(Spacer(1, 8))
+
+    # ── Common Missing Documentation Types ──
+    story.append(Paragraph("Common Missing Documentation Types", styles['SOPHeading']))
+    doc_types = [
+        "<b>Operative Report:</b> Required for surgical procedures (CPT 10000–69999). Must include surgeon name, pre/post-operative diagnosis, procedure details, findings, anesthesia type, and signature.",
+        "<b>Certificate of Medical Necessity (CMN):</b> Required for DME equipment (HCPCS E-codes). Must include physician signature, diagnosis, prognosis, and functional limitations.",
+        "<b>Delivery Ticket:</b> Required for DME to confirm patient received equipment. Must include patient signature, date of delivery, equipment description, and serial/lot number.",
+        "<b>Chart Notes / Clinical Documentation:</b> Required to support diagnosis and level of service. Must be from the date of service and signed by the rendering provider.",
+        "<b>Pathology Report:</b> Required when biopsy was performed. Must include specimen description, findings, and pathologist signature.",
+        "<b>Prescription / Written Order:</b> Required for DME, orthotics, and prosthetics. Must include prescribing physician signature, NPI, date, and equipment description.",
+    ]
+    for item in doc_types:
+        story.append(Paragraph(f"• {item}", styles['SOPBullet']))
+    story.append(Spacer(1, 6))
+
+    # ══════════════════════════════════════════════
+    # Resolution Workflow (maps to agent actions)
+    # ══════════════════════════════════════════════
+    story.append(Paragraph("Resolution Workflow", styles['SOPHeading']))
+    story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor('#0f3460')))
+    story.append(Spacer(1, 4))
+
+    # STEP 1: Identify the Denial (RCA Agent — Step 2,3,4)
+    story.append(Paragraph(
+        "STEP 1: Identify the Denial and Missing Documentation",
+        styles['SOPStepHeading']
+    ))
+    story.append(Paragraph(
+        "Review the Explanation of Benefits (EOB) to identify the exact denial code, remark codes, and what documentation is missing.",
+        styles['SOPBody']
+    ))
+    step1_bullets = [
+        "Retrieve the denied claim data from the claims database using the claim ID (rec_id)",
+        "Locate and read the EOB PDF file referenced in the claim record",
+        "Identify the primary denial code (CO-252) and associated remark code (e.g., M127)",
+        "Cross-reference the remark code with the table above to determine which document is needed",
+        "Note the CPT/HCPCS code to determine the document category (surgical → operative report, DME → CMN/delivery ticket)",
+        "Record the service date — all retrieved documents must correspond to this date",
+    ]
+    for b in step1_bullets:
+        story.append(Paragraph(f"• {b}", styles['SOPBullet']))
+    story.append(Spacer(1, 4))
+
+    # STEP 1A: Denial Summary
+    story.append(Paragraph(
+        "STEP 1A: Prepare Denial Summary",
+        styles['SOPStepHeading']
+    ))
+    story.append(Paragraph(
+        "Compile a denial summary (Intelligence Summary) that includes all relevant claim metadata, "
+        "the root cause analysis, and recommended resolution steps. This summary will be used by the "
+        "execution workflow to resolve the denial.",
+        styles['SOPBody']
+    ))
+    step1a_bullets = [
+        "Include: Claim ID, Invoice Number, Patient Name, Payer, Denial Code, Remark Codes, Service Date, Billed Amount",
+        "Include: Denial analysis explaining why the claim was denied and what is needed",
+        "Include: Specific SOP steps from this document that apply to the denial scenario",
+        "Include: Recommended Next Best Actions for the execution team",
+    ]
+    for b in step1a_bullets:
+        story.append(Paragraph(f"• {b}", styles['SOPBullet']))
+    story.append(Spacer(1, 6))
+
+    # STEP 2: Retrieve Documentation (Execution Agent — Step 2)
+    story.append(Paragraph(
+        "STEP 2: Retrieve Required Documentation from Provider / EHR System",
+        styles['SOPStepHeading']
+    ))
+    story.append(Paragraph(
+        "Query the provider portal or EHR (Electronic Health Record) system to retrieve the medical "
+        "documents needed to support the claim. Use the invoice number to look up available records.",
+        styles['SOPBody']
+    ))
+    step2_bullets = [
+        "Query the provider documentation system using the invoice number from the claim data",
+        "Retrieve all available documents associated with the claim (operative reports, chart notes, delivery tickets, prescriptions, etc.)",
+        "Verify that the retrieved documents match the date of service on the denied claim",
+        "Verify that the documents contain the required elements:",
+    ]
+    for b in step2_bullets:
+        story.append(Paragraph(f"• {b}", styles['SOPBullet']))
+
+    # Sub-bullets for document verification
+    verification_items = [
+        "Operative Report: Surgeon name, procedure performed, pre/post diagnosis, anesthesia, complications, date, and signature",
+        "Chart Notes: Provider name, date of service, assessment/plan, diagnosis codes, and signature",
+        "Delivery Ticket: Patient name, equipment description, serial/lot number, date of delivery, and patient signature",
+        "Prescription: Prescribing physician name, NPI, equipment ordered, diagnosis, date, and signature",
+        "CMN: Physician signature, diagnosis, prognosis, estimated length of need, and functional limitations",
+    ]
+    for v in verification_items:
+        story.append(Paragraph(f"  ◦ {v}", styles['SOPSubBullet']))
+    story.append(Spacer(1, 4))
+
+    story.append(Paragraph(
+        "<b>For CO-252 with M127 specifically:</b> The M127 remark code means \"Missing patient medical record "
+        "for this service.\" You must retrieve the operative report or chart notes from the provider that "
+        "document what was performed on the date of service. The document must include the surgeon's name, "
+        "procedure details, and be signed and dated.",
+        styles['SOPBody']
+    ))
+    story.append(Spacer(1, 6))
+
+    # STEP 3: Submit to Payer (Execution Agent)
+    story.append(Paragraph(
+        f"STEP 3: Submit Appeal Package to {payer['short']} Payer Portal",
+        styles['SOPStepHeading']
+    ))
+    story.append(Paragraph(
+        f"After retrieving the required documents, compile and submit the appeal package "
+        f"to the {payer['short']} payer portal.",
+        styles['SOPBody']
+    ))
+    step3_bullets = [
+        f"Generate a formal appeal letter indicating the denial code (CO-252), remark code, and list of documents retrieved",
+        f"Compile the appeal package: include the original claim reference (invoice number), the appeal letter, and all supporting documents retrieved from the provider/EHR system",
+        f"Submit via the {payer['short']} provider portal at {payer['portal']}",
+        "Include appeal notes that reference the denial code (CO-252), remark code (e.g., M127), and list the documents being submitted",
+        "Record the confirmation number returned by the payer portal — this is your proof of submission",
+        f"Submit within {payer['filing_deadline']} to avoid timely filing rejections",
+        "For package_path, use the format: docs/{{invoice_number}}/appeal_package.pdf",
+    ]
+    for b in step3_bullets:
+        story.append(Paragraph(f"• {b}", styles['SOPBullet']))
+    story.append(Spacer(1, 6))
+
+    # STEP 4: Update Case Notes (Execution Agent)
+    story.append(Paragraph(
+        "STEP 4: Create Case Summary and Update Provider Records",
+        styles['SOPStepHeading']
+    ))
+    story.append(Paragraph(
+        "After successful submission, create a comprehensive case summary and update the provider "
+        "database with all actions taken, confirmation numbers, and resolution status.",
+        styles['SOPBody']
+    ))
+    step4_bullets = [
+        "Draft a case summary that includes:",
+    ]
+    for b in step4_bullets:
+        story.append(Paragraph(f"• {b}", styles['SOPBullet']))
+
+    summary_items = [
+        "Original denial code and remark code (e.g., CO-252 / M127)",
+        "List of documents retrieved from the provider portal (type and file path)",
+        "Appeal submission confirmation number from the payer portal",
+        "Date and time of submission",
+        "Current status (e.g., Appeal Submitted, Pending Review)",
+    ]
+    for s in summary_items:
+        story.append(Paragraph(f"  ◦ {s}", styles['SOPSubBullet']))
+
+    step4_bullets_cont = [
+        "Present the draft case notes to the human reviewer for approval before updating the database",
+        "Update the provider database with the case notes, confirmation number, and updated status",
+        "Set the claim status to 'Submitted' after successful appeal submission",
+        "If the appeal is denied again, escalate to a formal Level 2 appeal or peer-to-peer review",
+    ]
+    for b in step4_bullets_cont:
+        story.append(Paragraph(f"• {b}", styles['SOPBullet']))
+    story.append(Spacer(1, 8))
+
+    # ── Specific Scenario: CO-252 + M127 ──
+    story.append(Paragraph("Specific Scenario: CO-252 with Remark Code M127", styles['SOPHeading']))
+    story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor('#e94560')))
+    story.append(Spacer(1, 4))
+
+    story.append(Paragraph(
+        "<b>Scenario:</b> A claim is denied with CO-252 and remark code M127 (\"Missing patient medical record "
+        "for this service\"). This is one of the most common CO-252 denial scenarios.",
+        styles['SOPBody']
+    ))
+    story.append(Paragraph(
+        "<b>Root Cause:</b> The payer requires the patient's medical record (operative report, chart notes, "
+        "or clinical documentation) for the date of service to adjudicate the claim, but this documentation "
+        "was not included with the original submission.",
+        styles['SOPBody']
+    ))
+
+    story.append(Paragraph("Resolution Steps for CO-252 / M127:", styles['SOPStepHeading']))
+    m127_steps = [
+        "<b>1. Identify the missing record type:</b> Check the CPT/HCPCS code on the denied claim. "
+        "Surgical codes (10000-69999) require an operative report. DME codes (E-codes) require a CMN and/or delivery ticket. "
+        "E&M codes (99201-99499) require chart notes.",
+        "<b>2. Query the provider portal:</b> Use the invoice number to retrieve all available medical records "
+        "from the provider/EHR system. Look specifically for operative reports, chart notes, and any other "
+        "clinical documentation matching the date of service.",
+        "<b>3. Verify document completeness:</b> Ensure the retrieved operative report or chart notes contain: "
+        "patient name, date of service, provider/surgeon name, procedure performed, pre/post-operative diagnosis, "
+        "and provider signature. If any element is missing, contact the provider to obtain a complete document.",
+        "<b>4. Generate appeal letter:</b> Generate a formal appeal letter indicating the denial code (CO-252), remark code (M127), and list the documents retrieved.",
+        f"<b>5. Submit to payer:</b> Package the retrieved documents along with the appeal letter and submit to {payer['short']} portal. "
+        "Include notes referencing denial code CO-252, remark code M127, and the documents being attached. "
+        "Record the confirmation number.",
+        "<b>6. Update provider records:</b> After submission, create a case summary with: the confirmation number, "
+        "list of documents submitted, submission date, and change the status to 'Submitted'. "
+        "Draft case notes and get human approval before writing to the provider database.",
+    ]
+    for step in m127_steps:
+        story.append(Paragraph(f"  {step}", styles['SOPBullet']))
+    story.append(Spacer(1, 8))
+
+    # ── Follow-up & Prevention ──
+    story.append(Paragraph("Follow-Up Timeline", styles['SOPHeading']))
+    followup = [
+        f"Allow 30 days for {payer['short']} to process the resubmitted claim with documentation",
+        "If no response after 30 days, contact the payer to check claim status",
+        "If denied again, review the new denial reason and escalate to formal appeal if needed",
+        f"All appeals must be filed within {payer['filing_deadline']}",
+    ]
+    for f_item in followup:
+        story.append(Paragraph(f"• {f_item}", styles['SOPBullet']))
+    story.append(Spacer(1, 6))
+
+    story.append(Paragraph("Prevention Tips", styles['SOPHeading']))
+    prevention = [
+        "Collect operative reports at time of claim submission for all surgical procedures",
+        "Obtain CMN before delivering any DME equipment",
+        "Always get signed delivery ticket with lot/serial number at time of DME delivery",
+        "Attach chart notes proactively for high-value claims or complex procedures",
+        "Verify payer-specific documentation requirements before initial billing",
+        "Use a claim scrubber tool to flag claims likely to receive CO-252 denials",
+    ]
+    for p in prevention:
+        story.append(Paragraph(f"• {p}", styles['SOPBullet']))
+
+
+def add_co16_section(story, payer, styles):
+    """Add the CO-16 denial resolution SOP section."""
+
+    add_metadata_table(
+        story, payer, "CO-16",
+        "CO-16 Denial Resolution — Claim Lacks Information / Billing Error",
+        styles
+    )
+
+    # ── Overview ──
+    story.append(Paragraph("Overview", styles['SOPHeading']))
+    story.append(Paragraph(
+        "CO-16 is a Claim Adjustment Reason Code (CARC) indicating that the claim lacks information or "
+        "has a billing/submission error that prevents adjudication. Unlike CO-252 (missing attachments), "
+        "CO-16 typically requires correcting information ON the claim form itself.",
+        styles['SOPBody']
+    ))
+    story.append(Paragraph(
+        "Common CO-16 issues include: invalid or non-specific diagnosis codes, missing modifiers, "
+        "missing referring provider NPI, missing ABN, or incorrect procedure code combinations.",
+        styles['SOPBody']
+    ))
+    story.append(Spacer(1, 4))
+
+    # ── Common CO-16 Reasons ──
+    story.append(Paragraph("Common CO-16 Denial Reasons", styles['SOPHeading']))
+    reasons = [
+        "<b>Invalid/Non-specific Diagnosis Code:</b> ICD-10 code is too general or not supported by documentation",
+        "<b>Missing Modifier:</b> Required modifier absent (e.g., telehealth modifier 95 or GT)",
+        "<b>Missing Referring Provider NPI:</b> Box 17b not populated when required",
+        "<b>Missing ABN:</b> Advance Beneficiary Notice not obtained for potentially non-covered service",
+        "<b>Invalid Procedure Code Combination:</b> CPT codes billed together that are not compatible",
+        "<b>Missing Secondary Diagnosis:</b> Additional codes required to support medical necessity",
+    ]
+    for r in reasons:
+        story.append(Paragraph(f"• {r}", styles['SOPBullet']))
+    story.append(Spacer(1, 6))
+
+    # ── Resolution Workflow ──
+    story.append(Paragraph("Resolution Workflow", styles['SOPHeading']))
+    story.append(HRFlowable(width="100%", thickness=1, color=colors.HexColor('#0f3460')))
+    story.append(Spacer(1, 4))
+
+    # Step 1
+    story.append(Paragraph("STEP 1: Identify the Billing Error", styles['SOPStepHeading']))
+    story.append(Paragraph(
+        "Review the EOB denial reason carefully to identify the specific information that is missing or incorrect.",
+        styles['SOPBody']
+    ))
+    s1_bullets = [
+        "Retrieve the denied claim data and EOB content",
+        "Identify the specific field or code that needs correction (diagnosis, modifier, NPI, etc.)",
+        "Cross-reference with the claim form (CMS-1500) to locate the field in question",
+    ]
+    for b in s1_bullets:
+        story.append(Paragraph(f"• {b}", styles['SOPBullet']))
+    story.append(Spacer(1, 4))
+
+    # Step 2
+    story.append(Paragraph("STEP 2: Review Supporting Documentation", styles['SOPStepHeading']))
+    s2_bullets = [
+        "Pull chart notes from the date of service",
+        "Identify the correct information to populate on the claim",
+        "Verify with the billing department or provider if needed",
+    ]
+    for b in s2_bullets:
+        story.append(Paragraph(f"• {b}", styles['SOPBullet']))
+    story.append(Spacer(1, 4))
+
+    # Step 3
+    story.append(Paragraph("STEP 3: Correct and Resubmit Claim", styles['SOPStepHeading']))
+    s3_bullets = [
+        "Correct the identified error on the CMS-1500 form",
+        "Generate a formal appeal letter indicating the denial code (CO-16), remark code, and list of supported documents",
+        "Submit as a corrected claim (not a new claim) and include the appeal letter",
+        "Include a brief explanation of the correction if required by the payer",
+        f"Submit via {payer['portal']}",
+    ]
+    for b in s3_bullets:
+        story.append(Paragraph(f"• {b}", styles['SOPBullet']))
+    story.append(Spacer(1, 4))
+
+    # Step 4
+    story.append(Paragraph("STEP 4: Document and Follow Up", styles['SOPStepHeading']))
+    s4_bullets = [
+        "Record all corrections made and the confirmation number",
+        "Update the internal claim notes with the correction details",
+        "Follow up in 30 days if no response received",
+        f"All corrections must be filed within {payer['filing_deadline']}",
+    ]
+    for b in s4_bullets:
+        story.append(Paragraph(f"• {b}", styles['SOPBullet']))
+    story.append(Spacer(1, 6))
+
+    # ── Prevention ──
+    story.append(Paragraph("Prevention Tips", styles['SOPHeading']))
+    prevention = [
+        "Use diagnosis codes at highest level of specificity available",
+        "Verify modifier requirements for telehealth, bilateral, and multiple procedure codes",
+        "Always populate referring provider NPI when service was referred",
+        "Obtain signed ABN before rendering services that may not be covered",
+        "Use a claim scrubber tool to catch errors before submission",
+    ]
+    for p in prevention:
+        story.append(Paragraph(f"• {p}", styles['SOPBullet']))
+
+
+def create_sop_pdf(payer_key, payer_config):
+    """Generate a complete SOP PDF for one payer."""
+    output_path = os.path.join(SOP_DIR, payer_config["filename"])
+    styles = build_styles()
+
+    doc = SimpleDocTemplate(
+        output_path,
+        pagesize=letter,
+        topMargin=0.6 * inch,
+        bottomMargin=0.6 * inch,
+        leftMargin=0.6 * inch,
+        rightMargin=0.6 * inch,
+    )
+
+    story = []
+
+    # Page 1-2: CO-16 SOP
+    add_co16_section(story, payer_config, styles)
+
+    # Page break
+    story.append(PageBreak())
+
+    # Page 3-4+: CO-252 SOP (the main one for our pipeline)
+    add_co252_section(story, payer_config, styles)
+
+    doc.build(story)
+    print(f"  ✓ Created: {output_path}")
+
+
+# ──────────────────────────────────────────────
+# Main
+# ──────────────────────────────────────────────
+if __name__ == "__main__":
+    print("Generating synthetic SOP PDFs for all payers...\n")
+
+    for payer_key, payer_config in PAYERS.items():
+        create_sop_pdf(payer_key, payer_config)
+
+    print(f"\n✅ {len(PAYERS)} SOP PDFs generated successfully!")
+    print("   Payers:")
+    for k, v in PAYERS.items():
+        print(f"     • {v['name']} → sop/{v['filename']}")
+    print("   ALL payer names are 100% fictitious.")
+    print("   Each SOP contains CO-16 and CO-252 resolution workflows.")
+    print("   CO-252 section includes specific M127 remark code scenario.")

sop/Crestview_Health.pdf

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+size 14407

sop/NationalCare.pdf

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sop/Summit_Health.pdf

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+size 14413