opdstar-nhi-mcp

Purpose

opdstar-nhi-mcp is an MCP server for Taiwan National Health Insurance (NHI) claim intelligence aimed at AI agents, powered by OPDSTAR. It enables Claude Desktop, Cursor, ChatGPT Desktop, Claude.ai, or any MCP-compatible client to directly query authoritative reference data on Taiwan NHI rejection codes, audit considerations, drug reimbursement regulations, reimbursed items, and payment standards in natural language.

Main Capabilities

This MCP server provides 27 tools, covering the following data and query capabilities:

• lookup_rejection_code: Query Taiwan NHI rejection codes (5 characters, e.g., 0317A).
• get_procedures_for_icd: Return applicable NHI procedure codes based on ICD-10 codes and specialty.
• get_indicator: Query Taiwan NHI audit indicators and thresholds.
• search_nhi_wiki: Perform semantic and full-text search on the official Taiwan NHI wiki (9 categories).
• get_drug_rules: Query Taiwan NHI drug reimbursement regulations; requires at least one filter condition.
• get_safe_phrases (preview only): Discover SOAP scenarios for known NHI safe phrasing in a specialty, returning the scenario, high-risk phrasing, the first sentence of a safe example, and a link to the full library; the full copy-ready phrasing library is a paid OPDSTAR product.
• search_audit_guidelines: Perform free-text search on audit consideration rules.
• get_rejection_code_category: List all NHI rejection codes under a category (00–09).
• lookup_drug: Query the Taiwan NHI drug directory (current reimbursement), searchable by generic name, brand name, alias, or NHI 9-character code.
• lookup_fee_code: Query the National Health Insurance medical service reimbursement items and payment standards (currently effective version), searchable by code, Chinese name, or English name.
• lookup_audit_clauses_for_procedure: Find official audit consideration clauses that cite a specific NHI procedure code.
• lookup_audit_clauses_for_specialty: Browse audit considerations by specialty.
• lookup_major_illness: Browse the official major illness and injury scope and items.
• check_icd_for_major_illness_eligibility: Reverse-query possible qualifying major illness and injury categories based on ICD-10 codes.
• lookup_audit_indicator: Query official analysis audit non-payment indicators.
• lookup_appeal_statistics_by_category: Return aggregated signals for dispute resolution by category (aggregated only, no case details).
• count_appeal_precedents_for_rejection_code: Return resolution volume and appellant win-rate signals involving a specific rejection or procedure code (aggregated only).
• recent_nhi_amendments: List NHIA medical expense audit consideration amendment announcements from the past year.
• search_taiwan_drug: Unified Taiwan drug query across NHI and TFDA registrations.
• lookup_icd10_cm: Query ICD-10-CM codes and their Chinese and English descriptions.
• search_nhi_interpretations: Search official Taiwan NHI administrative interpretations.
• lookup_preventive_service: Browse Taiwan NHI preventive care and screening services.
• lookup_chronic_prescription_rule: Query Taiwan NHI chronic disease continuous prescription rules.
• lookup_point_value: Query Taiwan NHI floating point values.
• lookup_sampling_audit_rules: Query professional review sampling audit indicators.
• lookup_special_material: Query Taiwan NHI special material reimbursement rules.
• lookup_p4p_program: Query Taiwan NHI care and pay-for-performance programs.

There are 10 rejection code categories in total: 00 Diagnosis and Treatment Quality, 01 Medical Records, 02 Basic Diagnosis and Treatment, 03 Drugs and Special Materials, 04 Surgery and Procedures, 05 Examinations and Tests, 06 Case Payment, 07 Rehabilitation and Psychiatry, 08 Other, 09 Laws and Regulations. All data is provided through the opdstar.com edge layer, with zero configuration and global cachstorage and response time under 100ms.

How to Use

Two usage paths are provided: Option A — Remote (one-click, no installation required): available via the Anthropic MCP Directory (listing under review). Point any MCP-compatible client at the hosted JSON-RPC 2.0 endpoint. For live status, tool list, and data freshness, see opdstar.com/mcp/status. Option B — Local (npm): requires Node.js 18+. Claude Desktop configuration: add to ~/Library/Application Support/Claude/claude_desktop_config.json (Mac) or %APPDATA%\Claude\claude_desktop_config.json (Windows), then restart Claude Desktop and you should see 27 tools in the tools menu. Cursor configuration: add to .cursor/mcp.json in the project root (or globally at ~/.cursor/mcp.json).

Applicable Scenarios

• Claim accuracy: will a given code/diagnosis combination be audited and clawed back? What is its pre-review status?
• Review guidelines: what do the NHI review points of caution stipulate for a given specialty/treatment?
• Drug rules: what are the NHI reimbursement rules for a given drug?
• Appeal precedents: has anyone filed an appeal against that clawback code? What are the success-rate signals?
• Reimbursement standards: what are the official point value and effective date of a given code?
• Chronic disease continuous prescriptions: whether a given disease falls within the chronic disease scope and its dispensing restrictions.
• Floating point value: estimate the actual reimbursement amount (claimed point value × point value ≈ payment amount).
• Sampling audit indicators: which clinics will be selected for professional claim review.
• Catastrophic illness: the catastrophic illness categories a given ICD-10 diagnosis may qualify for, indicating partial copayment exemption.

Limitations

This MCP focuses on Taiwan NHI-specific claim rules and reference data, and does not include: international standards (SNOMED CT, LOINC, FHIR R4 generation, RxNorm), drug interaction databases, clinical decision support/diagnostic recommendations, or general TFDA drug registration lookups (OPDSTAR only cross-references but does not copy them). Some data is curated by OPDSTAR rather than raw NHI data, for example lookup_fee_code's applicable_icd_pattern is OPDSTAR-curated and sparse; the raw NHI data has no ICD-10 mapping, and icd filtering only matches codes that have already been enriched. lookup_icd10_cm is currently backed by an OPDSTAR specialty-keyed Taiwan-relevant subset; the full CMS public-domain ICD-10-CM 2025 set will be merged in a later version. Sampling audit indicator thresholds are revised quarterly by each NHI division and are not interchangeable; divisions not covered return an empty result set, which does not mean that division has no rules. Special material rules may have superseded versions that read like current rules; by default only the effective version is shown. P4P program criteria are reference summaries; the final conditions are governed by the wording of the linked program. All tools are for reference purposes only; official announcements or final decisions rest with the respective institutions or physicians. For use only by Taiwan medical professionals and AI agent developers who need authoritative Taiwan NHI reference data.