Prior Authorization
Skill packages tagged with “Prior Authorization”
Appeal letter builder
Draft a denial-specific appeal letter grounded in the normalized denial reason, prior-therapy history, and payer policy. Enforces denial-reason rebuttal, plan-preferred-therapy failure arguments, contradiction checks, and appeal-specific completeness (RE line with denial date and reference number, rebuttal section, requested resolution, enclosure manifest including the LOMN). Hands the draft to the clinical-claim-evidence-mapper for citation and export gating.
Clinical claim evidence mapper
Persist a citation from every clinical claim (diagnosis, prior therapy, contraindication, lab value, score, outcome, coverage criterion, guideline) asserted in a drafted appeal or letter of medical necessity back to a chart excerpt. Blocks export of any drafting skill's output when claims are unmapped — the trust gate for all pilot-ready healthcare packets.
Denial intake normalizer
Parse payer denial letters, EOBs, Medicare Advantage IDNs, NOMNC/DENC, and appeal forms into a structured case.json. Classifies the denial, routes the appeal type, and computes the appeal deadline — the intake step for every downstream denial-appeal and prior-auth skill.
Letter of medical necessity builder
Draft a structured letter of medical necessity (LOMN) from a normalized case record and chart excerpts, using the Genentech/Novartis field model: patient identifiers, diagnosis and ICD-10, severity, prior therapies with outcomes, clinical rationale, treatment plan and dosing, supporting guidelines, and enclosure manifest. Enforces completeness, ICD-10 specificity, prior-therapy history structure, and disease-score capture before handing the draft to the clinical-claim-evidence-mapper for citation and export gating.
LOMN overlay — musculoskeletal / spine / pain
Specialty overlay for letter-of-medical-necessity-builder that applies stricter MSK, spine, orthopedic, and pain-management validations: conservative-care step-therapy rules per procedure (spine surgery, neurostimulator, RFA, ESI, facet injection, DME), ODI/NDI/VAS-pain trend analysis across baseline and post-conservative-care follow-up, and imaging-to-symptom concordance checks. Invoked from within the core LOMN workflow when the case specialty is MSK; adds requirements, does not weaken the core.
Packet checklist and index generator
Produce the evidence-bundle manifest for a denial-appeal or prior-authorization packet: required vs. optional attachments by denial category, service setting, and specialty; which items are attached; which are missing; and the structured manifest persisted to the workspace. Enforces inpatient-specific rules (complete medical records for acute inpatient appeals) and DMEPOS documentation lists. Consumes the normalized case record plus the drafted LOMN/appeal letter and their evidence map; produces the checklist, the packet-manifest JSON, and the human-readable packet index.
Peer-to-peer prep
Build a one-page pre-call briefing document for a scheduled peer-to-peer conversation between the clinic's physician and the payer's medical director. Renders the opening line, denial reason quoted verbatim, 60-second clinical story, prior-therapy table, contraindications to preferred alternatives, specialty-society guideline citation, a specific ask, and likely reviewer questions with prepared answer frames. Grounded in Patient Advocate Foundation peer-to-peer guidance and common denial-category-specific reviewer-question patterns.
Submission companion sheet
Produce the routing cover sheet for submitting a denial-appeal, claim-reconsideration, or prior-authorization packet to a US payer. Encodes channel selection (fax vs. portal vs. mail), expedited-flag handling, member and claim identifiers, attachment count, and certified-mail reminders. The routing-lookup is scaffolded as patterns (Anthem pre-service vs. retro vs. expedited fax separation; UHC PRA-driven claim-reconsideration routing; CoverMyMeds for PA; payer portals) rather than hardcoded fax numbers — the clinic's routing table is injected at pilot time. Pairs with packet-checklist-and-index-generator (which produces the attachment manifest this cover sheet lists).