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.
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.
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
waypoints/
├── assessment.json # Subskill 1 output (consolidated)
└── decision.json # Subskill 2 output (final decision)
This skill requires 3 healthcare MCP connectors:
For detailed tool usage, parameters, and CMS web resources, see references/01-intake-assessment.md.
During execution, the skill displays notifications before and after each MCP connector call:
See README.md File Organization section for complete directory structure and file descriptions.
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 for:
Quick Summary:
To customize decision logic for your organization, edit references/rubric.md.
Simply invoke the skill:
Use the prior-auth-review-skill
The skill will:
When this skill is invoked:
Before proceeding, verify required MCP connectors are available.
Check for the following MCP connectors:
If any MCP connectors are not configured:
Display error and exit:
"Missing required MCP connectors: [list missing connectors]. This skill requires all three healthcare MCP connectors to function. Please configure the missing connectors and try again. See README Prerequisites for setup instructions."
Exit skill.
If all MCP connectors are available: Proceed silently to next step.
Prompt the user to provide input files or use sample data.
Display the following prompt:
Prior Authorization Review requires the following input files:
REQUIRED FILES:
1. Prior Authorization Request Form (PDF) - Contains member info, requested service, provider details
2. Clinical Notes / H&P (PDF) - History and physical examination documentation
3. Diagnostic Imaging Reports (PDF) - CT, MRI, X-ray, or other imaging results
4. Laboratory Results (PDF) - Relevant lab work supporting medical necessity
5. Additional Supporting Documentation (PDF, optional) - PFTs, specialist consults, etc.
OPTIONS:
(A) Upload your own files - Provide paths to each required document
(B) Use sample files - Load pre-configured sample case (CT-guided lung biopsy)
Enter your choice (A/B): ___
If user selects (A) - Upload own files:
using_sample_files = FalseIf user selects (B) - Use sample files:
assets/sample/:
01_Prior_Auth_Request_Form.pdf02_Clinical_Notes_H_and_P.pdf03_CT_Chest_Report.pdf04_Laboratory_Results.pdf05_Pulmonary_Function_Tests.pdfusing_sample_files = True1234567890) and sample member ID (1EG4-TE5-MK72). This combination triggers demo mode, which skips the NPI MCP lookup for this specific provider only. All other MCP calls (ICD-10 validation, CMS Coverage policy search) execute normally.Check if waypoints/assessment.json exists:
If exists and incomplete:
Found incomplete PA request: [Request ID]
Resume this request? (Y/N): ___
If does not exist:
Execute: Read and follow references/01-intake-assessment.md
What it does:
Output: waypoints/assessment.json (consolidated)
Duration: 3-4 minutes
Ask user:
Ready to proceed to Subskill 2? (Y/N): ___
Execute: Read and follow references/02-decision-notification.md
What it does:
Output:
waypoints/decision.json (final decision)outputs/notification_letter.txt (provider notification)Duration: 1-2 minutes
Display a concise completion message with:
Offer user options to:
Missing MCP Servers: If required MCP connectors not available, display error listing missing connectors and Removefully.
Missing Subskill Prerequisites:
If Subskill 2 invoked without waypoints/assessment.json, notify user to complete Subskill 1 first.
File Write Errors: If unable to write waypoint files, display error with file path, check permissions/disk space, and offer retry.
Data Quality Issues: If clinical data extraction confidence <60%, warn user with confidence score and low-confidence areas. Offer options to: continue, request additional documentation, or abort.
For all errors, provide clear, actionable messages and user options for resolution.
Before completing workflow, verify:
Always read subskill files: Don't execute from memory. Read the actual subskill markdown file and follow instructions.
Auto-detect resume: Check for existing waypoints/assessment.json on startup. If found and status is not "assessment_complete", offer to resume.
Parallel MCP execution: In Subskill 1, execute NPI, ICD-10, and Coverage MCP calls in parallel for optimal performance.
Preserve user data: Never overwrite waypoint files without asking confirmation or backing up.
Clear progress indicators: Show users what's happening during operations (MCP queries, data analysis).
Graceful degradation: If optional data missing, continue with available data and note limitations.
Validate outputs: Check that waypoint files have expected structure before proceeding.
CRITICAL: Every time you invoke an MCP tool or WebFetch for code validation:
BEFORE the call:
AFTER receiving results:
If there's an issue:
Benefits:
Requirements:
waypoints/assessment.json (consolidated)waypoints/decision.json and notification letter