prior-auth-review-skill

Automating prior authorization review involves validating credentials, checking coverage policies, and generating auditable recommendations. This Skill handles intake, policy matching, and evidence extraction to determine APPROVE, PEND, or DENY outcomes across Medicare, Medicaid, and commercial plans.

AI handles clinical data mapping during prior auth intake by extracting structured data from submitted requests. It then performs parallel validation against NPI, ICD-10, and CMS Coverage databases to ensure accurate policy matching and evidence synthesis.

Yes, you can use this prior auth skill for Medicare, commercial, and Medicaid plans. It applies configurable rubrics to PA requests across these payer types to generate consistent decision outputs and provider notification letters.

The best way to ensure auditability in prior authorization decisions is to generate structured waypoints and audit artifacts throughout the review process. This Skill produces these artifacts alongside intake and assessment workflows for transparent human review and sign-off.

Automated prior auth review does not replace human medical review but supports it. The Skill generates auditable recommendations and provider notification letters that are explicitly ready for optional human review and final sign-off before a decision is finalized.