Encode Toolkit vs Opdstar Nhi MCP

lookup_rejection_code

Look up a single Taiwan NHI rejection code (5-character format `NNNNL` — 4 digits + 1 uppercase letter A/B/C/..., e.g. '0317A', '0338A', '0114A'). Returns severity (low / medium / high), category (00 診療品質 · 01 病歷紀錄 · 02 基本診療 · 03 藥品特材 · 04 手術處置 · 05 檢查檢驗 · 06 論病例計酬 · 07 復健精神 · 08 其他 · 09 法令 — first two digits encode the category), and the official Chinese description from 健保署 專業審查不予支付理由代碼. Returns a not-found message (not an error) if the code does not exist. **Use when** an agent encounters a known rejection code in a notice or claim response and needs the human-readable explanation, or when triaging which category a code belongs to. **Typical follow-up**: call `get_drug_rules({rejection_code})` if the code is in category 03 (藥品特材) to surface the drug rule behind the rejection; call `search_audit_guidelines({query: <code>})` for codes in 04 / 05 to read the underlying audit-clause text; call `count_appeal_precedents_for_rejection_code({rejection_code})` to gauge whether disputes for this code are commonly successful. **Don't use** to enumerate codes by category — call `get_rejection_code_category({category})` instead. **Reference only** — the official 健保署 code list is authoritative. Curated by OPDSTAR (https://opdstar.com).

get_procedures_for_icd

Given a Taiwan ICD-10 code and a medical specialty, return the NHI procedure codes plausibly applicable to that diagnosis within that specialty. Each result includes the procedure code, Chinese name, English name, nhi_points (payment points), and audit_notes (specialty-specific review caveats and risk hints). Results are ordered by curated relevance (most commonly applied codes first), capped at `limit` (default 10, max 20). Returns an empty list (not an error) when no curated mapping exists for the given (icd10, specialty) pair — this is common because the mapping is intentionally conservative. **Use when** an agent is drafting SOAP and needs a starting set of procedure codes for the diagnosis within the clinician's specialty context — e.g. dermatologist with `L30.9` (chronic eczema) needs candidate procedure codes. **Typical follow-up**: for each candidate code, call `lookup_fee_code({q: <code>})` to confirm current points and effective dates, and `lookup_audit_clauses_for_procedure({procedure_code})` to surface any audit-clause caveats. **Don't use** as a billing source of truth — the original NHI fee schedule has no ICD field, this is a curated, intentionally conservative mapping that prefers false negatives over false positives; for the canonical fee-schedule entry of a known code, call `lookup_fee_code`. **Reference only** — final code selection remains the clinician's responsibility. Curated by OPDSTAR (https://opdstar.com).

get_indicator

Look up a single Taiwan NHI prescribing-pattern indicator. These are short codes (numeric, or 'P'-prefixed) that encode common over-prescribing patterns such as antibiotic-on-URI, multi-drug co-prescribing, or duration limits. Returns the indicator name, the threshold (e.g. '7-day URI episode'), applicable drugs / diagnoses, and the compliance meaning. Returns a not-found message (not an error) if the code does not exist. **Use when** an agent needs the human-readable explanation for a specific indicator code referenced during a SOAP review or audit response — e.g. an audit notice cites an indicator and the agent needs to surface what it monitors and why a prescription tripped it. **Typical follow-up**: call `get_drug_rules({rejection_code})` with the indicator's downstream rejection code to read the formal payment rule, or `search_audit_guidelines({query})` to read related audit-clause text. **Don't use** for the official 分析審查不予支付指標 (percentage-cap audit) list — that's a different system — call `lookup_audit_indicator` instead. **Reference only** — thresholds and applicable lists reflect published guidance and may change with each NHI release; agents should re-read the indicator each session rather than caching values across sessions. Curated by OPDSTAR (https://opdstar.com).

search_nhi_wiki

Search across Taiwan's official NHI knowledge base (健保署全球資訊網) for natural-language background questions. Covers 9 categories: audit (審查 — review rules / rejection grounds), drugs (藥品特材 — formulary, payment limits), fees (費用 — copay, premiums, contribution), plans (醫療計畫 — disease-management programs), services (醫療服務 — covered benefits), insurance (投保 — enrollment), forms (表單 — applications), records (紀錄 — documentation rules), admin (行政 — contracting, accreditation). Returns up to 10 ranked excerpts (most relevant first); each result includes title, content snippet, source URL, and category tag. Returns an empty list (not an error) when the query has no matches. **Use when** an agent needs broad NHI policy background not tied to a specific code — e.g. '慢性病連續處方箋天數上限' / 'how does balance billing work for orthodontics' / 'what are the rules for telemedicine reimbursement'. **Typical follow-up**: when an excerpt mentions a specific code (e.g. '0317A', '00101B'), call the appropriate code-specific tool (`lookup_rejection_code`, `lookup_fee_code`) for the canonical entry. **Don't use** when you already know a specific rejection code, procedure code, drug name, or audit-clause topic — those have dedicated tools that return structured fields rather than excerpts. **Reference only** — official 健保署 publications are authoritative; ranked excerpts may lag the latest revision and the snippet is not the full document. Curated by OPDSTAR (https://opdstar.com).

search_nhi_interpretations

Search Taiwan's official NHI administrative interpretations (健保署行政函釋 / 函令) — the binding 公告 and 解釋函 issued by the National Health Insurance Administration that clarify how payment rules, drug-formulary provisions, special-material coverage, and review policy apply in practice. Each result returns the official document number (字號), issue date, 主旨 (subject), a content excerpt, and the source URL on the government law portal. Returns up to 10 ranked excerpts (most relevant first); returns an empty list (not an error) when nothing matches. **Use when** a question turns on an official ruling rather than a code definition — e.g. '函釋怎麼說人工水晶體的給付規定' / 'is there an interpretation on continuous-prescription day limits' — or when the user cites a 函釋 文號 directly (e.g. 健保審字第 1090017813 號). **Don't use** when you already have a specific rejection code, fee code, or drug name — those have dedicated lookup tools (`lookup_rejection_code`, `lookup_fee_code`, `lookup_drug`). **Reference only** — the official 健保署 / 衛福部 publication is authoritative; an excerpt may lag the latest revision and is not the full document, so open the source URL for the binding text. Curated by OPDSTAR (https://opdstar.com).

get_drug_rules

Look up Taiwan NHI drug payment rules (藥品給付規定) — when a drug class is / isn't reimbursable, with severity and source citation. Filter by `specialty`, `rejection_code`, or `drug_category_query` (at least one required). **Use when** an agent is checking whether a drug choice will trigger a rejection before submission, or wants to read the rule behind a known rejection code. **Don't use** to identify a specific drug (brand / generic / strength) — call `lookup_drug` instead; for the underlying audit clauses, use `lookup_audit_clauses_for_procedure` or `lookup_audit_clauses_for_specialty`. **Reference only** — official 健保藥品給付規定 is authoritative; curated subset, not exhaustive. Curated by OPDSTAR (https://opdstar.com).

get_safe_phrases

Preview which documentation scenarios have OPDSTAR-curated NHI-safe phrasing patterns for a given specialty (e.g. dermatology + 抗生素) — returns scenario name, high-risk wording to avoid, the key difference, and the first sentence of the safe-phrasing example. Up to 5 scenarios per call. **Use when** an agent is helping draft SOAP wording and needs to flag risky phrasing before submission. **Don't use** to retrieve full ready-to-copy templates (full library is part of the paid OPDSTAR product — link the user to opdstar.com); for the underlying audit rule that motivates a safe phrase, call `search_audit_guidelines`. **Reference only** — phrasing patterns reflect curated review experience, not formal NHI directives. Curated by OPDSTAR (https://opdstar.com).

search_audit_guidelines

Free-text search over Taiwan NHI 審查注意事項 rules — returns reason + suggestion summaries (first sentence only) for up to 10 rules matching a keyword (Traditional Chinese or English). **Use when** an agent is exploring whether any audit rule covers a topic (e.g. '抗生素', '檢查頻率', '慢性病處方') without knowing a specific code. **Don't use** for clauses tied to a known procedure code — call `lookup_audit_clauses_for_procedure` instead. Full SOAP example templates and detailed reasoning are part of the paid OPDSTAR product. **Reference only** — official 健保署 審查注意事項 is authoritative; results are previews. Curated by OPDSTAR (https://opdstar.com).

get_rejection_code_category

Browse Taiwan NHI rejection codes by category (00-09) for discovery — returns code, severity, and short description, up to 50 per call. Categories: 00 診療品質 · 01 病歷紀錄 · 02 基本診療 · 03 藥品特材 · 04 手術處置 · 05 檢查檢驗 · 06 論病例計酬 · 07 復健精神 · 08 其他 · 09 法令. **Use when** an agent needs to enumerate all rejection codes within a workflow domain (e.g. all surgery-handling codes). **Don't use** to look up a known specific code — call `lookup_rejection_code` instead. **Reference only** — official 健保署 不予支付理由代碼 is authoritative. Curated by OPDSTAR (https://opdstar.com).

lookup_drug

Look up the active Taiwan NHI drug catalog by generic name, brand name, NHI drug code, or alias — returns up to 10 matches with strength, dosage form, route, ATC code, therapeutic class, and brand list. **Use when** an agent needs to identify or disambiguate a drug before recommending dosage / formulation in a SOAP draft. **Don't use** to look up payment / reimbursement rules for the drug — call `get_drug_rules` instead; for an audit clause referencing the drug, call `search_audit_guidelines`. **Reference only** — official 健保署 藥品給付項目及支付標準 is authoritative; the catalog is a working snapshot. Curated by OPDSTAR (https://opdstar.com).

lookup_fee_code

Look up the Taiwan NHI fee schedule (全民健康保險醫療服務給付項目及支付標準, current effective edition). Search by exact code (e.g. '00101B', 'P15001') or by Chinese / English name (e.g. '門診診察', 'ICU') — returns code, points, effective dates, and audit notes (truncated to 600 chars). Use `category` prefix to scope ('00' 基本診療, '06' 手術, 'P1' 病例計酬, 'N2' 護理). **Use when** an agent needs the canonical fee entry for a known procedure code, or wants to discover codes by name. **Don't use** for drugs (call `lookup_drug`) or for ICD-10 → procedure suggestions (call `get_procedures_for_icd`). The optional `icd` filter applies an OPDSTAR-curated mapping that is intentionally sparse (the original NHI data has no ICD field) — most codes will return no result with `icd` active. **Reference only** — official 健保署 支付標準 is authoritative. Curated by OPDSTAR (https://opdstar.com).

lookup_audit_clauses_for_procedure

Find Taiwan NHI 審查注意事項 clauses that reference a specific procedure code (e.g. '00101B', '51017C') — each result indicates whether the clause carries an amount limit, frequency rule, or indication restriction (critical signals for rejection-risk assessment). Returns clause summary, specialty, and risk flags. **Use when** an agent has a candidate procedure code and needs to surface the audit context attached to it. **Don't use** for the procedure's fee-schedule entry (points / effective dates) — call `lookup_fee_code`; for browsing all clauses within a specialty, call `lookup_audit_clauses_for_specialty`. **Reference only** — clause summaries are first-sentence previews; official 健保署 審查注意事項 is the source of truth. Curated by OPDSTAR (https://opdstar.com).