Prior Authorization Review Assistant

An AI-powered assistant for insurance prior authorization review workflows that cross-references payer coverage criteria, clinical practice guidelines, and patient medical records to streamline the prior authorization process. Originally developed as an official Anthropic skill, this tool helps clinicians and administrative staff build medical necessity arguments, identify required supporting documentation, and draft appeal letters when authorizations are denied.

Quick Install

npx skills add Open-Medica/open-medical-skills --skill prior-authorization-review

What It Does

• Coverage criteria matching: Analyzes the requested service or medication against payer-specific coverage policies, identifying which medical necessity criteria must be met and documenting how the patient's clinical situation satisfies each requirement
• Step therapy verification: Determines whether step therapy (fail-first) requirements apply, identifies which prior treatments the patient has already tried, and documents therapeutic failures or contraindications that justify skipping steps
• Supporting documentation assembly: Identifies and lists the specific clinical documents (lab results, imaging reports, specialist notes, prior treatment records) needed to support the authorization request, flagging any gaps
• Peer-to-peer preparation: Generates structured clinical talking points for physician peer-to-peer review calls with insurance medical directors, organized around the relevant coverage criteria and clinical guideline recommendations
• Appeal letter drafting: When an authorization is denied, the skill produces a clinical appeal letter citing applicable medical literature, guideline recommendations, and patient-specific factors that establish medical necessity

Clinical Use Cases