Prior Auth Review Skill

What it does

This skill enables AI agents to analyze and verify insurance pre-authorizations for healthcare services. It cross-references patient eligibility, coverage details, and specific procedure codes against payer requirements to determine approval status before treatment occurs.

When to use it

• Pre-service verification: Check if a scheduled MRI or specialist consult is covered under a patient's current plan.
• Claim denial prevention: Identify missing documentation or incorrect coding that could cause an insurance claim to be rejected later.
• Cost estimation accuracy: Confirm whether a service will be fully covered, partially covered, or require out-of-pocket payment.
• Compliance auditing: Review historical authorization records to ensure all necessary approvals were obtained prior to rendering care.

Key capabilities

• Validates patient eligibility against specific insurance policies.
• Interprets complex CPT and HCPCS procedure codes for coverage rules.
• Identifies gaps in pre-authorization documentation.
• Flags potential denials based on medical necessity criteria.

Example prompts

• "Review the pre-authorization status for a 70-year-old patient requesting a knee replacement under Plan ID #4592."
• "Check if this specific MRI procedure requires prior approval and list the missing documents needed for submission."
• "Analyze the coverage details for a pediatric asthma management plan and determine if the requested inhaler is covered."

Tips & gotchas

Ensure you have access to real-time payer databases or up-to-date policy documents, as insurance rules change frequently. Always verify that the patient's demographic data matches the eligibility records exactly to avoid false negatives in authorization checks.