medical_prior_authorization v1.0.0

name: medical_prior_authorization description: "Work a US health insurance prior authorization from order to decision: check whether the service needs authorization for that plan, read the payer policy for the specific service, build the clinical evidence packet in reviewer order with a criterion by criterion map, submit and track it against the decision clock that actually applies, and on a denial run same day triage, a prepared peer to peer, and a written appeal keyed to the stated denial reason. Triggers when a prior authorization is pending, pended for more information, or denied, when a peer to peer or appeal deadline is in play, or when a practice wants fewer preventable denials."

Medical Prior Authorization

Purpose

Get a medically ordered service authorized without preventable delay: the right request, with the evidence the payer policy actually asks for, pointed at precisely, tracked against a real deadline, and answered the same day if the first answer is no.

Most denials are not a judgment that care is wrong. They are a record problem: a criterion the packet never addressed, evidence that was in the chart but never pointed at, a code that did not match the order, or a deadline nobody calendared. KFF's analysis of 2023 Medicare Advantage data makes the point in numbers: only 11.7 percent of denied prior authorization requests were appealed, and 81.7 percent of the appeals that were filed were partially or fully overturned. The work in this skill is building the first packet so it reads as clearly as a good appeal, and appealing properly when the case meets criteria and the payer still says no.

Scope limits, plainly: this skill covers prior authorization for medical items and services in US health plans. Drug authorization runs on the pharmacy benefit, with formulary and exception rules that differ by plan, and the federal rule cited most here, CMS-0057-F, does not apply to drugs at all. This skill is workflow and evidence practice, not legal advice and not medical advice. The treating clinician owns the clinical argument. A case headed for litigation, a fraud allegation, or a benefits question under a specific ERISA plan goes to the people qualified for that, with the tracking record attached.

Workflow

1. Confirm authorization is actually required, for this plan, this service, and this place of service. Check the payer's authorization list for the member's plan and the eligibility record for the date of service. Filing where none is required wastes the clock, and not filing where one is required is the cheapest denial to prevent and the hardest to cure after the service.

1. Check for a live authorization first. A second request that contradicts an approval already on file creates a mess neither side can read. For Medicare Advantage, an approval for a course of treatment stays valid as long as that course is medically necessary, and a member who changed Medicare Advantage plans mid course has a 90 day transition period in which the new plan may not require prior authorization for that active course of treatment.

1. Pull the payer policy for the specific service, in the version in effect for the relevant date, and work from its criteria. Not from memory, not from the last case for a different plan, and not from a general guideline the payer never adopted. The criteria list is the checklist the packet is built against, word for word.

1. Build the packet in reviewer order, using references/packet-checklist.md. Cover sheet with the identifiers and the exact service, signed and dated order, a one page criteria map tying each criterion to a dated document and a location inside it, then the notes and prior treatment records the map cites, in date order. Send what the criteria require. Do not send the whole chart and hope the reviewer finds the page that matters.

1. Write the criteria map honestly. Mark each criterion met, not met, or does not apply, with the evidence pointer or the reason. Where a criterion is not met, make the clinical case in that row: what was tried, why an alternative does not fit this patient, what the treating physician expects to change based on the result. A hidden gap becomes a documentation denial. A stated gap with a clinical argument is a case a reviewer can approve or a peer to peer can win.

1. Set urgency from the clinical facts, and prove it when you claim it. An expedited request needs a short urgency statement naming what changes for the patient if the service waits for a standard decision. Claiming expedited handling without that statement, or as a routine way to jump the queue, gets the request handled as standard and costs credibility for the case that truly cannot wait.

1. Submit through the channel the payer specifies for that plan, and capture the reference number, the date and time, and the channel before closing the task. No reference number means no case the payer can find when you call. Log the decision due date at submission:

• For an impacted payer under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), meaning a Medicare Advantage organization, a state Medicaid or CHIP fee for service program, a Medicaid or CHIP managed care plan, or a Qualified Health Plan issuer on a Federally Facilitated Exchange: from January 1, 2026 the payer must give a specific reason for any denial, and, except for Qualified Health Plan issuers on the federal Exchanges, must send a decision within 72 hours for an expedited request and 7 calendar days for a standard request, counted from receipt. Program rules can allow an extension in defined cases, so treat those dates as the deadline to check against, and read any extension notice the payer sends.
• For any other plan, including commercial and self funded employer plans: the due date comes from the plan documents, the provider contract, or state law for that case. Write down which source you used. Do not borrow the CMS dates for a plan they do not cover.
• From January 1, 2027, impacted payers must also run a Prior Authorization API that lists covered items and services, states documentation requirements, and returns approvals with their end date, denials with a specific reason, or requests for more information. Where that API is live and connected to the record system, use it. The packet and map work stays the same. Run scripts/pa_check.py on the case file to check packet completeness and print the clocks that apply.

bash
python3 ~/workspace/skills/medical-prior-authorization/scripts/pa_check.py case.json

Exit code 0 means the packet is complete and no denial action is open, 1 means gaps or open actions were found, 2 means the case file is malformed. A full example case is in references/worked-case.json, told end to end in references/worked-case.md.

1. Track to decision, do not wait passively. Check status before the due date, answer a request for more information with exactly the element asked for plus a pointer note keyed to the criterion it supports, and log every call with date, name or identifier given, and what was said. If the due date passes with no decision, escalate in writing the next business day, citing the submission reference and the rule or plan term that set the date.

1. On approval, verify before scheduling. Authorization number, service and code authorized, units or visits, validity dates, and place of service, checked against the order. An approval for the wrong code or a window that closes before the scheduled date is a denial that has not happened yet.

1. On denial, run same day triage from references/denial-and-appeal.md. Read the specific reason, split the denial into administrative, documentation, or clinical, log every deadline in the notice, request a peer to peer the same day when one is offered for a clinical denial, and calendar the internal appeal deadline. The peer to peer window in the notice is normally the shortest clock in the case and the one most often lost by waiting.

1. Prepare the peer to peer as a one page brief for the treating physician, and write the appeal, if one is needed, as a one to two page letter that answers the stated reason, quotes the payer criterion from the version in effect on the denial date, and maps dated evidence to it. Structure and escalation steps, including external review, are in references/denial-and-appeal.md.

1. Close the case in the tracking record either way: final outcome, authorization details or final denial level reached, and what would have prevented the delay. Review closed cases monthly by payer and denial reason. A reason that repeats is a packet or workflow defect to fix at step 3 or 4, not a fact of life.

Output Contract

Every case worked with this skill produces:

• The tracking record entry: payer and plan type, service and code, dates ordered and submitted, channel and reference number, decision due date with the source that set it, decision and date
• The criteria map used for the submission, with an evidence pointer on every criterion marked met
• The packet as sent, or a manifest listing its elements in order
• On a request for more information: what was asked, what was sent in response, and when
• On approval: the verification check of number, code, units, validity dates, and place of service against the order
• On denial: the same day triage note (kind of denial, specific reason, policy cited, all deadlines logged), the peer to peer brief and its outcome note, and the appeal letter if filed, with its filing date and proof of submission
• The checker output for the case file, kept with the case

Operating Rules

• The denial notice and the plan documents control the deadlines in a case. General rules in this skill set floors and defaults for covered plans only. Where a notice and a general rule disagree, follow the notice, note the disagreement, and do not let either clock lapse while sorting it out.
• Never state a payer specific window, a number of appeal days, or a turnaround time as universal. Payers set peer to peer windows individually, appeal deadlines differ by plan type, and Medicare programs run their own appeal levels instead of the HealthCare.gov external review track.
• For plans under the federal external review rules, the request is due within 4 months after the final internal denial notice, a standard review is decided within 45 days, an expedited review within 72 hours, and the result binds the plan. File the internal appeal on time even while pursuing any other help, because no complaint path extends an appeal deadline by itself.
• Under Medicare Advantage rules, a medical necessity denial must be reviewed by a physician or other appropriate health care professional with expertise appropriate to the service at issue. If a denial record shows that did not happen, raise it once, in writing, as part of the appeal.
• Also under Medicare Advantage rules, where traditional Medicare coverage criteria are fully established, a plan may not use internal criteria more restrictive than those criteria. Where they are not fully established, internal criteria must be based on widely used treatment guidelines or clinical literature. Name which limb you are relying on when you use this argument.
• Keep patient information inside the systems the practice already authorizes for it. A case file for the checker uses an internal case reference, never a name, member ID, or date of birth. The worked example in this skill is fictional.
• Survey and population figures, such as the AMA physician survey findings on delay and burden, or the KFF overturn figure, are context for why the work matters. They are never evidence in a patient's case and never a promise about an outcome.
• The 2025 AMA prior authorization survey, as reported by the AMA, found practices complete an average of 40 prior authorizations per physician per week at about 13 hours a week, with 95 percent of physicians reporting that prior authorization delays access to necessary care. Cite it as a survey of physicians, not as a measurement of any one practice.