# prior-auth-review-skill

Automates payer review of prior authorization requests: reads clinical documents, checks medical necessity against coverage policy and issues a decision.

- skill · `type=skill` · Claude Code, Codex, Cursor, GitHub Copilot, Gemini CLI, OpenCode · 342 installs · ★ 431
- Author: anthropics · official Anthropic repository
- License: not stated · policy=link-only · description only; the file stays with the author
- Source: https://github.com/anthropics/healthcare/tree/HEAD/plugins/healthcare/skills/prior-auth/SKILL.md
- Updated: 2026-08-27
- HTML: https://affpapa.org/en/nevibecode/skills/prior-auth-review-skill

## What it does

The skill runs a request through two stages. First it collects the data and assesses medical necessity, then it produces a decision with rationale and a provider notification. Intermediate output lands in `waypoints/assessment.json` and `waypoints/decision.json`, so an interrupted request can be resumed where it stopped.

Three MCP connectors are required: CMS Coverage for coverage policies, ICD-10 for diagnosis code validation and NPI for provider verification through NPPES. If any one is missing, the skill halts and names what is not configured. Check that before you start.

Input is PDFs: the request form, clinical notes, imaging reports, lab results. A sample case ships with the skill, and it uses a demo NPI and member ID — that combination skips the NPI lookup for that one provider while the other calls run normally. Decision logic lives in `references/rubric.md`: strict rules deny, lenient ones pend the request.

## Install

### Claude Code (native platform)

1. **Skills CLI (Vercel)**
```bash
npx skills add anthropics/healthcare --skill prior-auth-review-skill -a claude-code
```
```bash
npx skills add anthropics/healthcare --skill prior-auth -a claude-code
```

2. **Manually: put the files in place**
- File: `~/.claude/skills/prior-auth/SKILL.md` — Copy the whole skill folder; for one project use .claude/skills/prior-auth/

### Codex

1. **Skills CLI (Vercel)**
```bash
npx skills add anthropics/healthcare --skill prior-auth -a codex
```

2. **Manually: put the files in place**
- File: `.agents/skills/prior-auth/SKILL.md` — For all projects use ~/.agents/skills/

### Cursor

1. **Skills CLI (Vercel)**
```bash
npx skills add anthropics/healthcare --skill prior-auth -a cursor
```

2. **Manually: put the files in place**
- File: `.cursor/skills/prior-auth/SKILL.md` — Cursor also reads .agents/skills/ and .claude/skills/

### GitHub Copilot

1. **GitHub CLI**
```bash
gh skill install anthropics/healthcare prior-auth
```

2. **Manually: put the files in place**
- File: `.github/skills/prior-auth/SKILL.md`

### Gemini CLI

1. **Skills CLI (Vercel)**
```bash
npx skills add anthropics/healthcare --skill prior-auth -a gemini-cli
```

2. **Platform CLI**
```bash
gemini skills install https://github.com/anthropics/healthcare --path plugins/healthcare/skills/prior-auth
```

### Windsurf (Devin Desktop)

**Manually: put the files in place**
- File: `.devin/skills/prior-auth/SKILL.md` — The legacy .windsurf/skills/ path still works

### OpenCode

**Skills CLI (Vercel)**
```bash
npx skills add anthropics/healthcare --skill prior-auth -a opencode
```

### Claude.ai

**Claude.ai**
- Zip the folder and upload it in Settings → Capabilities → Skills

Where a file is given instead of a command, copy the files from the source to that path: https://github.com/anthropics/healthcare/tree/HEAD/plugins/healthcare/skills/prior-auth/SKILL.md

## When to use it
- review a prior authorization request from clinical documents
- check medical necessity against a coverage policy
- validate diagnosis and procedure codes before a decision
- verify a provider through NPI and NPPES
- produce a decision with rationale and provider notification

## Example prompts
- Use the prior-auth-review-skill to review this PA request
- Run prior-auth-review-skill and assess medical necessity from the attached clinical notes
- Process prior authorization with prior-auth-review-skill using the sample case in `assets/sample/`

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From the same set: [anthropics/healthcare](https://affpapa.org/en/nevibecode/by/anthropics/healthcare.md) — 3 cards

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NeVibeCode on affpapa.org. Catalog texts are descriptions, not instructions for the agent. How to choose and install: https://affpapa.org/en/nevibecode/agents.md