prior-auth-review-skill

To automate prior authorization intake, this Skill extracts clinical evidence, validates provider credentials and medical codes, and matches diagnoses to Medicare LCD/NCD criteria to draft a policy-based medical necessity decision. It produces a structured decision package ready for human sign-off.

The best way to match coverage policy is by extracting provider-submitted clinical context and validating it against Medicare LCD/NCD criteria. This Skill generates a policy-aligned authorization outcome with evidence and a complete audit justification.

Prior authorization workflow automation requires healthcare MCP connectors for CMS Coverage, ICD-10, and NPI validation. It also uses controlled web validation for CPT/HCPCS codes via official CMS resources to ensure accurate medical coding and provider credential checks.

To generate an audit trail for prior authorization, this Skill produces waypoint JSON outputs and notification artifacts while enforcing rubric-driven human oversight. It requires explicit human confirmation before finalizing the policy-based authorization outcome and provider notification.

Yes, you can use this for health insurance payer workflows requiring ICD-10 and CPT/HCPCS validation. It validates medical codes via healthcare MCP connectors and official CMS resources, applying coverage policy matching to provider-submitted documentation.

A key limitation is that automating medical necessity reviews cannot finalize decisions autonomously. The process enforces rubric-driven human-in-the-loop oversight, requiring explicit professional sign-off on the drafted policy-based authorization outcome and audit justification.