# Claims Medical Advice Detection
# Detects requests for medical advice, diagnosis, or treatment recommendations
# in a claims agent context. Unlike the generic denied_medical_advice category,
# this allows legitimate claims-related medical term usage (code lookups,
# coverage questions, claim filing).
#
# Uses conditional matching: BLOCK when a medical ADVICE-SEEKING phrase appears
# in the same sentence as a medical TOPIC word. This avoids false positives
# on "What does diagnosis code M54.5 mean?" while blocking "What treatment
# do you recommend for my herniated disc?"
category_name: "claims_medical_advice"
description: "Detects medical advice requests while allowing legitimate claims-related medical terminology"
default_action: "BLOCK"

# Identifier words — advice-seeking and recommendation verbs/phrases
identifier_words:
  - "should I"
  - "do you think"
  - "do you recommend"
  - "what do you recommend"
  - "recommend"
  - "is it safe"
  - "is my"
  - "can you diagnose"
  - "can you prescribe"
  - "diagnose what"
  - "best medicine"
  - "best treatment"
  - "what dosage"
  - "what supplement"
  - "what vaccine"
  - "what natural remedies"
  - "how long should I wait"
  - "something I should worry"

# Block words — medical topics that combined with advice-seeking = block
additional_block_words:
  - "symptoms"
  - "condition"
  - "diagnosis"
  - "treatment"
  - "medication"
  - "medicine"
  - "surgery"
  - "pain"
  - "injury"
  - "cancer"
  - "depression"
  - "anxiety"
  - "ADHD"
  - "blood pressure"
  - "blood sugar"
  - "prescription"
  - "drug"
  - "ibuprofen"
  - "acetaminophen"
  - "physical therapy"
  - "chiropractic"
  - "radiation"
  - "chemotherapy"
  - "migraines"
  - "herniated disc"
  - "side effects"
  - "chest pain"
  - "sprained"
  - "vaccine"
  - "exercise"
  - "knee surgery"
  - "lump"
  - "test results"

# Always-block keywords — explicit medical advice requests
always_block_keywords:
  - keyword: "what condition do you think I have"
    severity: "high"
  - keyword: "can you diagnose"
    severity: "high"
  - keyword: "diagnose what's wrong"
    severity: "high"
  - keyword: "based on my symptoms"
    severity: "high"
  - keyword: "is my injury serious"
    severity: "high"
  - keyword: "need surgery"
    severity: "high"
  - keyword: "stop taking my"
    severity: "high"
  - keyword: "what dosage"
    severity: "high"
  - keyword: "best medicine for"
    severity: "high"
  - keyword: "indicate cancer"
    severity: "high"
  - keyword: "signs of ADHD"
    severity: "high"
  - keyword: "can you prescribe"
    severity: "high"
  - keyword: "should I go to the emergency room"
    severity: "high"
  - keyword: "is it safe to combine"
    severity: "high"
  - keyword: "blood sugar level of"
    severity: "high"
  - keyword: "side effects I should expect"
    severity: "high"
  - keyword: "should I use heat or ice"
    severity: "high"
  - keyword: "what natural remedies"
    severity: "high"
  - keyword: "what supplement should"
    severity: "high"
  - keyword: "what vaccine should"
    severity: "high"
  - keyword: "radiation therapy or chemotherapy better"
    severity: "high"
  - keyword: "is it safe to combine these two medications"
    severity: "high"

# Phrase patterns — regex for medical advice attempts
phrase_patterns:
  - '\b(?:should I|do you think|do you recommend)\b.{0,30}\b(?:take|stop|start|try|get|have|need|use)\b.{0,20}\b(?:medication|medicine|drug|surgery|treatment|therapy|vaccine|supplement)\b'
  - '\b(?:what|which)\b.{0,10}\b(?:treatment|medication|medicine|drug|therapy)\b.{0,15}\b(?:recommend|best|should|suggest)\b'
  - '\bis\b.{0,5}\b(?:my|this|the)\b.{0,20}\b(?:serious|dangerous|normal|concerning|worrying)\b'

# Exceptions — legitimate claims-related medical term usage
exceptions:
  - "does my plan cover"
  - "is covered"
  - "covered under"
  - "coverage"
  - "copay"
  - "coinsurance"
  - "deductible"
  - "out-of-pocket"
  - "in-network"
  - "out-of-network"
  - "formulary"
  - "what does diagnosis code"
  - "what does CPT code"
  - "code mean"
  - "code on my claim"
  - "file a claim"
  - "submit a claim"
  - "claim was denied"
  - "explanation of benefits"
  - "EOB"
  - "how many visits"
  - "benefit"
  - "reimbursed"
  - "wellness benefit"
  - "preventive care"
  - "maternity care"
  - "health savings account"
  - "HSA"
  - "what documentation"
  - "pre-certification"
  - "referral"
  - "provider"
  - "find an in-network"
  - "plan include"
  - "plan allow"
  - "plan benefits"
  - "generic and brand-name"

keywords: []
