What problem does it solve?
Prior authorization reviews are time-consuming, inconsistent, and often lack clear, auditable rationale. This skill streamlines payer review by validating provider credentials and codes, matching clinical evidence to CMS coverage policies, and producing a structured decision package for human sign-off.
Core Features & Use Cases
- Parallel MCP Validation: Simultaneously verify provider NPI, batch-validate ICD-10 codes, and search CMS coverage policies for fast turnaround.
- Procedure Code Validation: Validate CPT/HCPCS via WebFetch to official CMS fee schedule sources.
- Clinical Extraction & Policy Matching: Extract structured clinical findings, map evidence to policy criteria, and evaluate each criterion with confidence scores.
- Audit-Ready Outputs: Produce waypoints/assessment.json, waypoints/decision.json, audit_justification.md, and provider notification letters with an auditable MCP invocation trail.
- Human-in-the-Loop Safety: Enforce rubric-based recommendations with explicit human review, override logging, and clear error handling for missing connectors or low-confidence extraction.
- Use Case Example: Payers can auto-assess straightforward PA requests (e.g., imaging or procedures) to auto-approve clear cases and pend ambiguous ones while documenting all sources and rationale.
Quick Start
Provide the PA request files, provider NPI, CPT and ICD codes, then ask the skill to assess medical necessity and generate the assessment and decision package.
