prior-auth-review-skill

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---
name: prior-auth-review-skill
description: 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.
---

# 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)
```

---

## Prerequisites

### Required MCP Servers

This skill requires 3 healthcare MCP connectors:

1. **CMS Coverage MCP Connector** - Medicare coverage policies (NCDs, LCDs)
2. **ICD-10 MCP Connector** - Diagnosis code validation and lookup
3. **NPI MCP Connector** - Healthcare provider verification via NPPES

**For detailed tool usage, parameters, and CMS web resources, see [references/01-intake-assessment.md](references/01-intake-assessment.md#prerequisites).**

### MCP Invocation Notifications

During execution, the skill displays notifications before and after each MCP connector call:
- Before: "Verifying provider credentials via NPI MCP Connector..."
- After: "NPI MCP Connector completed successfully - Provider verified: Dr. [Name]"
- Before: "Validating diagnosis codes via ICD-10 MCP Connector..."
- After: "ICD-10 MCP Connector completed successfully - [N] codes validated"
- Before: "Searching coverage policies via CMS Coverage MCP Connector..."
- After: "CMS Coverage MCP Connector completed successfully - Found policy: [Policy ID]"
- Before: "Validating procedure codes via CMS Fee Schedule..."
- After: "CPT/HCPCS codes validated via CMS Fee Schedule - [N] codes checked"

### File Structure

See README.md File Organization section for complete directory structure and file descriptions.

---

## 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](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](references/rubric.md).

---

## How to Use

### Process PA Request

Simply invoke the skill:

```
Use the prior-auth-review-skill
```

The skill will:
1. Check for incomplete requests (auto-resume if found)
2. Collect PA request details
3. Execute Subskill 1: Intake & Assessment
4. Execute Subskill 2: Decision & Notification
5. Output authorization decision pack