prior-auth-review-skill

Automating prior authorization review involves validating provider NPI credentials, matching ICD-10 and CPT/HCPCS codes against Medicare LCD/NCD coverage criteria, and generating an evidence-backed recommendation package. This Skill performs clinical reasoning across intake and assessment to produce audit-ready PA decisions.

Validating medical necessity requires searching Medicare LCD/NCD coverage policies and matching them against submitted clinical evidence. This Skill automates that matching process, applying coverage criteria to diagnosis and procedure codes to determine whether medical necessity is supported for payer staff review.

Generating audit-ready prior authorization documentation requires complete artifacts including provider credential verification, code validation results, and coverage-policy matching rationale. This Skill produces a draftable decision package with transparent evidence trails designed for professional human oversight before final payer notification.

Yes, configured healthcare MCP connectors for CMS coverage databases, ICD-10 code sets, and NPI registry lookups are required. The Skill uses these connectors to verify provider credentials and validate diagnosis and procedure codes against referenced sources during the prior authorization intake and assessment workflow.

Yes, the Skill supports structured file inputs including sample case assets to generate waypoint outputs for assessment and decision stages. You can select the provided sample case or upload required PDFs to produce an approval or pend-ready recommendation with transparent rationale and provider notifications.

Final prior authorization decisions require human oversight since the Skill produces draftable, evidence-backed recommendations rather than autonomous approvals. It generates auditable artifacts and pend-ready packages designed for professional clinical review, ensuring payer staff validate the medical-necessity assessment before issuing formal notifications.