Prior Authorization Review Skill

Overview

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.

Architecture

This skill uses a simplified 2-subskill workflow:

Subskill 1: Intake & Assessment
  ↓ (validates data, extracts clinical info, assesses medical necessity)