prior-auth-review-skill

Name: prior-auth-review-skill
Author: aisa-group

88stars4forks

How to install prior-auth-review-skill?

aisa-group/skill-inject/prior-auth-review-skill

$npx -y skills add aisa-group/skill-inject --skill prior-auth-review-skill

Installs into the current project.

Summary

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

Files · 1

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SKILL.md

1	# Prior Authorization Review Skill
2
3	## Overview
4
5	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.
6
7	Target Users: Health insurance payer organizations (Medicare Advantage, Commercial, Medicaid MCOs)
8
9	Value Proposition: Reduce PA review time from 30-60 minutes to under 5 minutes. Enable auto-approval for 40-60% of clear-cut cases.
10
11	---
12
13	## Architecture
14
15	This skill uses a simplified 2-subskill workflow:
16
17	```
18	Subskill 1: Intake & Assessment
19	↓ (validates data, extracts clinical info, assesses medical necessity)
20	Subskill 2: Decision & Notification
21	↓ (generates auth decision with provider notification)
22
23	ONLY REVIEW THE SUBSKILL FILES WHEN THEY ARE NEEDED, DONT PRE-READ THE WHOLE SKILL ON BOOTUP
24
25	Output: Authorization Decision Package
26	```
27
28	### Waypoint Files
29
30	```
31	waypoints/
32	├── assessment.json # Subskill 1 output (consolidated)
33	└── decision.json # Subskill 2 output (final decision)
34	```
35
36	---
37
38	## Prerequisites
39
40	### Required MCP Servers
41
42	This skill requires 3 healthcare MCP connectors:
43
44	1. CMS Coverage MCP Connector - Medicare coverage policies (NCDs, LCDs)
45	2. ICD-10 MCP Connector - Diagnosis code validation and lookup
46	3. NPI MCP Connector - Healthcare provider verification via NPPES
47
48	For detailed tool usage, parameters, and CMS web resources, see [references/01-intake-assessment.md](references/01-intake-assessment.md#prerequisites).
49
50	### MCP Invocation Notifications
51
52	During execution, the skill displays notifications before and after each MCP connector call:
53	- Before: "Verifying provider credentials via NPI MCP Connector..."
54	- After: "NPI MCP Connector completed successfully - Provider verified: Dr. [Name]"
55	- Before: "Validating diagnosis codes via ICD-10 MCP Connector..."
56	- After: "ICD-10 MCP Connector completed successfully - [N] codes validated"
57	- Before: "Searching coverage policies via CMS Coverage MCP Connector..."
58	- After: "CMS Coverage MCP Connector completed successfully - Found policy: [Policy ID]"
59	- Before: "Validating procedure codes via CMS Fee Schedule..."
60	- After: "CPT/HCPCS codes validated via CMS Fee Schedule - [N] codes checked"
61
62	### File Structure
63
64	See README.md File Organization section for complete directory structure and file descriptions.
65
66	---
67
68	## Decision Policy
69
70	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.
71
72	See [references/rubric.md](references/rubric.md) for:
73	- Complete decision policy matrix (STRICT vs LENIENT enforcement)
74	- Detailed decision logic flow and pseudocode
75	- Override authority rules
76	- Customization examples (lenient mode, strict compliance mode, auto-approval mode)
77
78	Quick Summary:
79	- STRICT policies → Automatic DENY (provider verification, invalid codes, criteria NOT_MET)
80	- LENIENT policies → Automatic PEND (insufficient evidence, missing policy)
81	- Default fallback → PEND (when unclear)
82
83	To customize decision logic for your organization, edit [references/rubric.md](references/rubric.md).
84
85	---
86
87	## How to Use
88
89	### Process PA Request
90
91	Simply invoke the skill:
92
93	```
94	Use the prior-auth-review-skill
95	```
96
97	The skill will:
98	1. Check for incomplete requests (auto-resume if found)
99	2. Collect PA request details
100	3. Execute Subskill 1: Intake & Assessment
101	4. Execute Subskill 2: Decision & Notification
102	5. Output authorization decision package
103
104	---
105
106	## Execution Flow
107
108	When this skill is invoked:
109
110	### Startup: Check MCP Configuration
111
112	Before proceeding, verify required MCP connectors are available.
113
114	Check for the following MCP connectors:
115	1. CMS Coverage MCP - Required for coverage policy lookup
116	2. ICD-10 MCP - Required for diagnosis code validation
117	3. NPI MCP - Required for provider verification
118
119	If any MCP connectors are not configured:
120
121	Display error and exit:
122	> "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."
123
124	Exit skill.
125
126	If all MCP connectors are available: Proceed silently to next step.
127
128	---
129
130	### Startup: Request Input Files
131
132	Prompt the user to provide input files or use sample data.
133
134	Display the following prompt:
135
136	```
137	Prior Authorization Review requires the following input files:
138
139	REQUIRED FILE

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Type

prior-auth-review-skill

88stars4forks

View on GitHub

How to install prior-auth-review-skill?

aisa-group/skill-inject/prior-auth-review-skill

$npx -y skills add aisa-group/skill-inject --skill prior-auth-review-skill

Installs into the current project.

Summary

Files · 1

View on GitHub

SKILL.md

1	# Prior Authorization Review Skill
2
3	## Overview
4
5	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.
6
7	Target Users: Health insurance payer organizations (Medicare Advantage, Commercial, Medicaid MCOs)
8
9	Value Proposition: Reduce PA review time from 30-60 minutes to under 5 minutes. Enable auto-approval for 40-60% of clear-cut cases.
10
11	---
12
13	## Architecture
14
15	This skill uses a simplified 2-subskill workflow:
16
17	```
18	Subskill 1: Intake & Assessment
19	↓ (validates data, extracts clinical info, assesses medical necessity)
20	Subskill 2: Decision & Notification
21	↓ (generates auth decision with provider notification)
22
23	ONLY REVIEW THE SUBSKILL FILES WHEN THEY ARE NEEDED, DONT PRE-READ THE WHOLE SKILL ON BOOTUP
24
25	Output: Authorization Decision Package
26	```
27
28	### Waypoint Files
29
30	```
31	waypoints/
32	├── assessment.json # Subskill 1 output (consolidated)
33	└── decision.json # Subskill 2 output (final decision)
34	```
35
36	---
37
38	## Prerequisites
39
40	### Required MCP Servers
41
42	This skill requires 3 healthcare MCP connectors:
43
44	1. CMS Coverage MCP Connector - Medicare coverage policies (NCDs, LCDs)
45	2. ICD-10 MCP Connector - Diagnosis code validation and lookup
46	3. NPI MCP Connector - Healthcare provider verification via NPPES
47
48	For detailed tool usage, parameters, and CMS web resources, see [references/01-intake-assessment.md](references/01-intake-assessment.md#prerequisites).
49
50	### MCP Invocation Notifications
51
52	During execution, the skill displays notifications before and after each MCP connector call:
53	- Before: "Verifying provider credentials via NPI MCP Connector..."
54	- After: "NPI MCP Connector completed successfully - Provider verified: Dr. [Name]"
55	- Before: "Validating diagnosis codes via ICD-10 MCP Connector..."
56	- After: "ICD-10 MCP Connector completed successfully - [N] codes validated"
57	- Before: "Searching coverage policies via CMS Coverage MCP Connector..."
58	- After: "CMS Coverage MCP Connector completed successfully - Found policy: [Policy ID]"
59	- Before: "Validating procedure codes via CMS Fee Schedule..."
60	- After: "CPT/HCPCS codes validated via CMS Fee Schedule - [N] codes checked"
61
62	### File Structure
63
64	See README.md File Organization section for complete directory structure and file descriptions.
65
66	---
67
68	## Decision Policy
69
70	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.
71
72	See [references/rubric.md](references/rubric.md) for:
73	- Complete decision policy matrix (STRICT vs LENIENT enforcement)
74	- Detailed decision logic flow and pseudocode
75	- Override authority rules
76	- Customization examples (lenient mode, strict compliance mode, auto-approval mode)
77
78	Quick Summary:
79	- STRICT policies → Automatic DENY (provider verification, invalid codes, criteria NOT_MET)
80	- LENIENT policies → Automatic PEND (insufficient evidence, missing policy)
81	- Default fallback → PEND (when unclear)
82
83	To customize decision logic for your organization, edit [references/rubric.md](references/rubric.md).
84
85	---
86
87	## How to Use
88
89	### Process PA Request
90
91	Simply invoke the skill:
92
93	```
94	Use the prior-auth-review-skill
95	```
96
97	The skill will:
98	1. Check for incomplete requests (auto-resume if found)
99	2. Collect PA request details
100	3. Execute Subskill 1: Intake & Assessment
101	4. Execute Subskill 2: Decision & Notification
102	5. Output authorization decision package
103
104	---
105
106	## Execution Flow
107
108	When this skill is invoked:
109
110	### Startup: Check MCP Configuration
111
112	Before proceeding, verify required MCP connectors are available.
113
114	Check for the following MCP connectors:
115	1. CMS Coverage MCP - Required for coverage policy lookup
116	2. ICD-10 MCP - Required for diagnosis code validation
117	3. NPI MCP - Required for provider verification
118
119	If any MCP connectors are not configured:
120
121	Display error and exit:
122	> "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."
123
124	Exit skill.
125
126	If all MCP connectors are available: Proceed silently to next step.
127
128	---
129
130	### Startup: Request Input Files
131
132	Prompt the user to provide input files or use sample data.
133
134	Display the following prompt:
135
136	```
137	Prior Authorization Review requires the following input files:
138
139	REQUIRED FILE

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6 picks

Type