Prior Authorization Clinical Policy Reasoning

Overview

Guide the agent through structured evaluation of prior authorization (PA) clinical policies, coverage determinations, step therapy protocols, and appeals processes. This skill encodes payer policy logic so the agent can assess whether a requested service meets authorization criteria, identify documentation gaps, and recommend appeal strategies.

Usage

• Invoke when evaluating whether a service meets prior authorization clinical criteria
• Use for step therapy evaluation, medical necessity assessment, or appeal strategy
• Activate for CMS LCD/NCD coverage rules or Da Vinci PAS implementation guidance

Core Concepts

Response Format