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prior-auth-review-skill

✓ Official★ 332

by anthropic · part of anthropics/healthcare

Automate payer review of prior authorization (PA) requests. This skill should be used when users say "Review this PA request", "Process prior authorization for [procedure]", "Assess medical necessity", "Generate PA decision", or when processing clinical documentation for coverage policy validation and authorization decisions.

🔥🔥🔥✓ VerifiedFreeQuick setup
#automation#git
🧰 Not standalone. This skill ships with anthropics/healthcare and only works together with that tool — install the tool first, then add this skill.

This is the playbook your agent receives when the skill activates — you don't need to read it to use the skill, but it's here to audit before installing.

Prior Authorization Review Skill

Overview

This skill automates the payer review process for prior authorization (PA) requests. It processes clinical documentation, validates medical necessity against coverage policies, and generates authorization decisions with supporting rationale.

Target Users: Health insurance payer organizations (Medicare Advantage, Commercial, Medicaid MCOs)

Value Proposition: Reduce PA review time from 30-60 minutes to under 5 minutes. Enable auto-approval for 40-60% of clear-cut cases.

Architecture

This skill uses a simplified 2-subskill workflow:

Subskill 1: Intake & Assessment
  ↓ (validates data, extracts clinical info, assesses medical necessity)
Subskill 2: Decision & Notification
  ↓ (generates auth decision with provider notification)

ONLY REVIEW THE SUBSKILL FILES WHEN THEY ARE NEEDED, DONT PRE-READ THE WHOLE SKILL ON BOOTUP

Output: Authorization Decision Package

Waypoint Files

waypoints/
├── assessment.json          # Subskill 1 output (consolidated)
└── decision.json           # Subskill 2 output (final decision)

Decision Policy

This skill enforces a decision policy rubric that determines the outcome when validation checks fail. The policy balances regulatory compliance, patient safety, and operational efficiency.

See references/rubric.md for:

  • Complete decision policy matrix (STRICT vs LENIENT enforcement)
  • Detailed decision logic flow and pseudocode
  • Override authority rules
  • Customization examples (lenient mode, strict compliance mode, auto-approval mode)

Quick Summary:

  • STRICT policies → Automatic DENY (provider verification, invalid codes, criteria NOT_MET)
  • LENIENT policies → Automatic PEND (insufficient evidence, missing policy)
  • Default fallback → PEND (when unclear)

To customize decision logic for your organization, edit references/rubric.md.

Execution Flow

When this skill is invoked:

Startup: Check MCP Configuration

Before proceeding, verify required MCP connectors are available.

Check for the following MCP connectors:

  1. CMS Coverage MCP - Required for coverage policy lookup
  2. ICD-10 MCP - Required for diagnosis code validation
  3. NPI MCP - Required for provider verification

If any MCP connectors are not configured:

Display error and exit:

"Missing required MCP connectors: [list missing connectors]. This skill requires all three healthcare MCP connectors to function. Please configure the missing connectors and try again. See README Prerequisites for setup instructions."

Exit skill.

If all MCP connectors are available: Proceed silently to next step.

Startup: Request Input Files

Prompt the user to provide input files or use sample data.

Display the following prompt:

Prior Authorization Review requires the following input files:

REQUIRED FILES:
1. Prior Authorization Request Form (PDF) - Contains member info, requested service, provider details
2. Clinical Notes / H&P (PDF) - History and physical examination documentation
3. Diagnostic Imaging Reports (PDF) - CT, MRI, X-ray, or other imaging results
4. Laboratory Results (PDF) - Relevant lab work supporting medical necessity
5. Additional Supporting Documentation (PDF, optional) - PFTs, specialist consults, etc.

OPTIONS:
(A) Upload your own files - Provide paths to each required document
(B) Use sample files - Load pre-configured sample case (CT-guided lung biopsy)

Enter your choice (A/B): ___

If user selects (A) - Upload own files:

  • Prompt for path to each required file
  • Validate files exist and are readable
  • Store file paths for use in Subskill 1
  • Set using_sample_files = False

If user selects (B) - Use sample files:

  • Load sample files from assets/sample/:
    • 01_Prior_Auth_Request_Form.pdf
    • 02_Clinical_Notes_H_and_P.pdf
    • 03_CT_Chest_Report.pdf
    • 04_Laboratory_Results.pdf
    • 05_Pulmonary_Function_Tests.pdf
  • Display: "Loading sample case: CT-guided transbronchial lung biopsy for 1.2cm RUL nodule"
  • Set using_sample_files = True
  • Demo mode note: When sample files are used, the sample data contains demo NPI (1234567890) and sample member ID (1EG4-TE5-MK72). This combination triggers demo mode, which skips the NPI MCP lookup for this specific provider only. All other MCP calls (ICD-10 validation, CMS Coverage policy search) execute normally.

Startup: Check for Existing Request

Check if waypoints/assessment.json exists:

  • If exists and incomplete:

    Found incomplete PA request: [Request ID]
Resume this request? (Y/N): ___
    • If Y: Load assessment and continue to Subskill 2
    • If N: Archive and start new

  • If does not exist:

    • Start from Subskill 1

Subskill 1: Intake & Assessment

Execute: Read and follow references/01-intake-assessment.md

What it does:

  1. Collect PA request information
  2. Validate provider credentials and codes (parallel MCP calls)
  3. Search coverage policies
  4. Extract clinical data
  5. Assess medical necessity against policy criteria
  6. Generate recommendation (APPROVE/DENY/PEND)

Output: waypoints/assessment.json (consolidated)

Duration: 3-4 minutes

Ask user:

Ready to proceed to Subskill 2? (Y/N): ___
  • If Y: Continue to Subskill 2
  • If N: Save and exit

Subskill 2: Decision & Notification

Execute: Read and follow references/02-decision-notification.md

What it does:

  1. Load assessment from Subskill 1
  2. Confirm or override recommendation
  3. Generate decision-specific content:
    • Approval: Auth number, validity dates, limitations
    • Denial: Specific reasons, policy references, appeal rights
    • Pend: Documentation requests, submission deadline
  4. Create provider notification letter
  5. Document audit trail

Output:

  • waypoints/decision.json (final decision)
  • outputs/notification_letter.txt (provider notification)

Duration: 1-2 minutes

Final Summary

Display a concise completion message with:

  • Request details (ID, member, service, decision outcome)
  • Authorization number and validity dates (if approved)
  • Files generated (waypoints and notification)
  • Next steps based on decision type

Offer user options to:

  1. View decision letter
  2. Start new PA review
  3. Exit

Error Handling

Missing MCP Servers: If required MCP connectors not available, display error listing missing connectors and Removefully.

Missing Subskill Prerequisites: If Subskill 2 invoked without waypoints/assessment.json, notify user to complete Subskill 1 first.

File Write Errors: If unable to write waypoint files, display error with file path, check permissions/disk space, and offer retry.

Data Quality Issues: If clinical data extraction confidence <60%, warn user with confidence score and low-confidence areas. Offer options to: continue, request additional documentation, or abort.

For all errors, provide clear, actionable messages and user options for resolution.

Quality Checks

Before completing workflow, verify:

  • All required waypoint files created
  • Decision has clear rationale documented
  • All required fields populated
  • Output files generated successfully

Subskill Descriptions

Subskill 1: Intake & Assessment (3-4 minutes)

  • Collects PA request details (member, service, provider, clinical docs)
  • Validates provider credentials via NPI MCP
  • Validates and retrieves ICD-10 code details via ICD-10 MCP (single batch call)
  • Validates CPT/HCPCS codes via WebFetch to CMS Fee Schedule
  • Searches coverage policies via CMS Coverage MCP
  • Extracts structured clinical data from documentation
  • Maps clinical evidence to policy criteria
  • Performs medical necessity assessment
  • Generates recommendation (APPROVE/DENY/PEND)
  • Output: waypoints/assessment.json (consolidated)
  • Data Sources: NPI MCP, ICD-10 MCP, CMS Coverage MCP (parallel), CMS Fee Schedule (web)

Subskill 2: Decision & Notification (1-2 minutes)

  • Loads assessment from Subskill 1
  • Confirms or allows override of recommendation
  • Generates authorization number (if approved) or denial rationale (if denied)
  • Creates provider notification letter
  • Documents complete audit trail
  • Output: waypoints/decision.json and notification letter