Outpatient Authorization Decision Engine
Generate defensible outpatient authorization decisions from clinical criteria and payer guidelines
What You Can Do
Analyze outpatient authorization requests against clinical evidence, payer guidelines, and regulatory standards to generate clear approval or denial recommendations with documented medical necessity justification. The skill transforms scattered clinical notes, procedure codes, insurance guidelines, and patient history into structured determinations that withstand peer-to-peer reviews, appeals, and regulatory audits while reducing decision time from hours to minutes.
Features
compares procedure requests against evidence-based guidelines (MCG, InterQual, Milliman) and payer-specific medical policies
generates explicit reasoning that justifies approval or denial decisions with specific clinical evidence
evaluates patient risk factors and existing conditions that impact authorization decisions
identifies relevant prior approvals and treatment history to prevent duplicative or contradictory determinations
structures clinical rationale for overturning payer denials with organized evidence presentation
organizes key clinical findings and guideline citations for physician reviewer conversations
formats determinations with decision logic, evidence citations, and regulatory compliance markers
highlights procedures requiring enhanced scrutiny (joint replacements, advanced imaging, specialty infusions)
Example Output
Request: Pre-authorization for MRI of right knee, patient age 65 with osteoarthritis and 6-week conservative treatment history
Determination: APPROVED — Medical necessity met
- Patient meets InterQual criteria for advanced imaging (conservative treatment ≥6 weeks documented)
- Age 65 with chronic OA qualifies under payer guidelines
- No prior imaging within 12 months (no duplication)
- Decision defensible in appeal: supports clinical decision-making for potential surgical candidacy
Request: Pre-authorization for PT course (25 visits), patient with acute ankle sprain, 1-week duration
Determination: CONDITIONAL APPROVAL — Approve initial 10 visits, requires concurrent review at visit 10
- Meets criteria for acute injury PT initiation
- 25-visit request exceeds standard protocol for uncomplicated ankle sprain
- Concurrent review flags potential overutilization
- Clinical rationale: Protects both patient access and payer interests through structured reassessment
What's Included
- SKILL.md: Core instruction file with decision-making framework and clinical criteria integration
- Authorization Request Template: Standardized intake form capturing clinical history, procedure codes, insurance guidelines, and comorbidities
- Decision Documentation Checklist: Audit-ready format ensuring medical necessity language, evidence citations, and regulatory compliance markers
- Appeal Preparation Worksheet: Structured guide for building override cases with organized clinical evidence and guideline references
- High-Cost Procedure Workflow: Decision matrix for complex cases (joint replacements, specialty infusions, advanced imaging) with enhanced scrutiny points
Who It's For
- Utilization Review Managers — Streamline daily authorization decisions while maintaining audit compliance and appeal readiness
- Medical Directors — Review UM determinations with confidence using explicitly documented clinical reasoning and guideline alignment
- Insurance Medical Reviewers — Generate consistent determinations across cases with defensible documentation
- Appeals Specialists — Build override cases with organized clinical evidence and regulatory support
- Outpatient Clinical Teams — Understand authorization rationale and optimize case presentations for approval
Best For
- Pre-authorization requests for scheduled outpatient procedures (surgery, imaging, PT, infusions, diagnostics)
- Concurrent reviews for ongoing outpatient treatments with utilization monitoring
- Denial appeals requiring explicit medical necessity documentation and guideline-based rationale
- Complex cases with comorbidities, prior authorizations, or high-cost procedures
- Peer-to-peer review preparation with organized clinical evidence and decision support
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