Prior Authorization Coworker

This skill acts as an automated utilization management reviewer. It takes unstructured clinical notes and a procedure code, compares them against internal policy criteria (e.g., conservative therapy failure), and renders a decision.

When to Use This Skill

• When a user asks to "review a prior auth request".
• When checking if a patient qualifies for a specific procedure (e.g., MRI).
• When you need to generate a structured approval/denial letter justification.

Core Capabilities

1. Policy Matching: Checks against specific criteria (e.g., "Pain > 6 weeks").
2. Trace Generation: Produces an "Anthropic-style" <thinking> trace for auditability.
3. Structured Output: Returns a JSON object with decision, reasoning, and timestamps.

Workflow

1. Extract Data: Parse the clinical note and procedure code from the user's input.
2. Execute Review: Run the coworker script.
3. Present Decision: Output the JSON decision and the reasoning trace.

Example Usage

User: "Check if this patient qualifies for an MRI of the Lumbar Spine: Patient has had back pain for 2 months, tried PT but it didn't work."

Agent Action:

python3 Skills/Clinical/Prior_Authorization/anthropic_coworker.py --code "MRI-L-SPINE" --note "Patient has back pain > 2 months. Failed PT."

Supported Policies

• MRI-L-SPINE (Lumbar Spine MRI)