{
  "schema": "aibast-canonical-transcripts/1.0",
  "captured_at": "2026-10-07T01:52:25.542312+00:00",
  "solution": "@aibast-agents-library/prior-authorization",
  "onepager": "47. Prior Authorization Agent one-pager.pptx",
  "brainstem_version": "0.6.16",
  "loaded_tools_after_capture": [
    "PriorAuthorizationAgent"
  ],
  "agent_sources": [
    {
      "path": "agents/@aibast-agents-library/healthcare_stacks/prior_authorization_stack/prior_authorization_agent.py",
      "sha256": "474c2429fae7cf94c1e625b6a99092e329b606e81dd29c58f1dbf1d5d4c3a05b"
    }
  ],
  "case_file": "tests/demo_cases/prior-authorization.json",
  "case_file_sha256": "21c9b6b4df591a84a3f9a7e66dfba23f44eac8481aa2732f9bef972b9bc0e4d1",
  "strict_isolation": true,
  "transcripts": [
    {
      "case_id": "PA-01",
      "persona": "Utilization Management Coordinator",
      "onepager_promise": "Compile the full clinical evidence packet needed for medical review",
      "prompt": "What evidence is present or missing for synthetic request SYN-AUTH-001?",
      "assistant_response": "Here's the evidence snapshot for **SYN-AUTH-001** (synthetic knee imaging request):\n\n- **Payer:** Synthetic Health Plan, policy SYN-POL-IMG-01\n- **Status in source:** Additional evidence requested (as of 2026-07-30)\n\n**Present:**\n- Encounter note \u2705\n- Prior imaging report \u2705\n\n**Missing:**\n- Conservative-care duration \u2014 not found in the synthetic source\n\nThat missing piece (how long conservative treatment was tried before imaging) is likely what the payer flagged when they asked for more evidence. Note this is all synthetic demo data \u2014 a real reviewer would still need to confirm against actual payer policy before any submission.",
      "agent_logs": "[PriorAuthorizationAgent] # Prior-Authorization Evidence Inventory\n\n> Synthetic demonstration data only. This output is a read-only evidence draft, not an authorization, eligibility, medical-necessity, diagnosis, or treatment decision. A qualified utilization reviewer must verify payer policy and clinical evidence before any submission.\n\n## SYN-AUTH-001: synthetic knee imaging request\n- Payer in synthetic source: Synthetic Health Plan\n- Source-recorded workflow state: additional evidence requested (2026-07-30)\n- Referenced policy: SYN-POL-IMG-01\n\n- encounter note: present\n- prior imaging report: present\n- conservative-care duration: not found in synthetic source\n",
      "expected_agent": "PriorAuthorizationAgent",
      "must_include": [
        "SYN-AUTH-001",
        "additional evidence requested"
      ],
      "model": "claude-sonnet-5",
      "requested_model": "claude-sonnet-5",
      "passed": true
    },
    {
      "case_id": "PA-02",
      "persona": "Nurse Case Manager",
      "onepager_promise": "Pull payer-specific requirements and match them with EHR data",
      "prompt": "Show the synthetic criteria checklist for SYN-AUTH-001 without deciding medical necessity.",
      "assistant_response": "Here's the synthetic criteria checklist for SYN-AUTH-001 (imaging evidence request):\n\n**Policy effective date:** 2026-07-01\n\n**Checklist items for reviewer verification:**\n- \u2610 Relevant encounter note on file\n- \u2610 Prior imaging evidence documented\n- \u2610 Documented duration fields present\n\nNote: this is purely a presence/absence checklist \u2014 it doesn't establish medical necessity or make any authorization determination. A qualified utilization reviewer still needs to verify these against actual payer policy and clinical evidence before anything gets submitted. This is synthetic demo data only.",
      "agent_logs": "[PriorAuthorizationAgent] # Criteria-to-Evidence Crosswalk\n\n> Synthetic demonstration data only. This output is a read-only evidence draft, not an authorization, eligibility, medical-necessity, diagnosis, or treatment decision. A qualified utilization reviewer must verify payer policy and clinical evidence before any submission.\n\n## SYN-AUTH-001 \u2014 Synthetic Imaging Evidence Checklist\n- Synthetic policy effective date: 2026-07-01\n- Checklist only; presence does not establish medical necessity or authorization.\n- Reviewer check: relevant encounter note\n- Reviewer check: prior imaging evidence\n- Reviewer check: documented duration fields\n",
      "expected_agent": "PriorAuthorizationAgent",
      "must_include": [
        "Synthetic Imaging Evidence Checklist",
        "Checklist only"
      ],
      "model": "claude-sonnet-5",
      "requested_model": "claude-sonnet-5",
      "passed": true
    },
    {
      "case_id": "PA-03",
      "persona": "Radiology Scheduler",
      "onepager_promise": "Submit requests directly to payer portals and send real-time updates",
      "prompt": "What workflow state is recorded for SYN-AUTH-001, and what does it not mean?",
      "assistant_response": "SYN-AUTH-001 is recorded as **\"additional evidence requested\"** as of 2026-07-30.\n\nWhat it doesn't mean:\n- It's not an agent-generated determination \u2014 it's a direct transcription from the source system.\n- It's not a denial, approval, or prediction of outcome.\n- It doesn't confirm eligibility, medical necessity, or treatment decisions.\n\nAny submission or next step still needs a qualified utilization reviewer to verify against current payer policy.",
      "agent_logs": "[PriorAuthorizationAgent] # Source-Recorded Status Summary\n\n> Synthetic demonstration data only. This output is a read-only evidence draft, not an authorization, eligibility, medical-necessity, diagnosis, or treatment decision. A qualified utilization reviewer must verify payer policy and clinical evidence before any submission.\n\n- SYN-AUTH-001: additional evidence requested as recorded on 2026-07-30\n  - This is a source transcription, not an agent determination.",
      "expected_agent": "PriorAuthorizationAgent",
      "must_include": [
        "SYN-AUTH-001",
        "not an agent determination"
      ],
      "model": "claude-sonnet-5",
      "requested_model": "claude-sonnet-5",
      "passed": true
    },
    {
      "case_id": "PA-04",
      "persona": "Utilization Management Coordinator",
      "onepager_promise": "Prepare appeal materials proactively",
      "prompt": "Prepare a minimum-necessary reconsideration evidence outline for SYN-AUTH-001.",
      "assistant_response": "Here's the minimum-necessary reconsideration outline for **SYN-AUTH-001** (synthetic demo data):\n\n**Status:** Additional evidence requested\n**Policy to verify:** SYN-POL-IMG-01\n\n**Suggested outline (reviewer to finalize):**\n1. **Request summary** \u2014 original auth ID, service, date, denial/pended reason tied to SYN-POL-IMG-01\n2. **Minimum necessary clinical evidence** \u2014 only the specific findings/notes the policy requires (e.g., conservative-treatment duration, symptom documentation) \u2014 avoid including unrelated chart history\n3. **Policy-criteria mapping** \u2014 line up each payer requirement against the specific evidence item that satisfies it\n4. **Gap disclosure** \u2014 note anything not yet supported, so the reviewer can decide whether to obtain it before submitting\n5. **Reviewer sign-off block** \u2014 space for the human UR reviewer to confirm necessity, accuracy, and authorization to submit\n\nThis is a draft outline only \u2014 it doesn't predict outcomes, grant/deny anything, or submit. A qualified reviewer needs to verify the policy details and complete the clinical rationale before anything goes out. Want me to pull the underlying request/criteria evidence to help fill in section 2 or 3?",
      "agent_logs": "[PriorAuthorizationAgent] # Reconsideration Evidence Draft\n\n> Synthetic demonstration data only. This output is a read-only evidence draft, not an authorization, eligibility, medical-necessity, diagnosis, or treatment decision. A qualified utilization reviewer must verify payer policy and clinical evidence before any submission.\n\nA reviewer must confirm that reconsideration or appeal is appropriate and permitted.\n\n## SYN-AUTH-001\n- Source workflow state: additional evidence requested\n- Policy reference to verify: SYN-POL-IMG-01\n- Include only authorized, minimum-necessary evidence.\n- Human utilization reviewer owns rationale, completeness, and submission.\n",
      "expected_agent": "PriorAuthorizationAgent",
      "must_include": [
        "minimum-necessary evidence",
        "reviewer must confirm"
      ],
      "model": "claude-sonnet-5",
      "requested_model": "claude-sonnet-5",
      "passed": true
    },
    {
      "case_id": "PA-05",
      "persona": "Utilization Management Coordinator",
      "onepager_promise": "Pull payer-specific requirements and match them with EHR data",
      "prompt": "Patient Robert Chen needs prior auth for a lumbar MRI ordered by Dr. Thompson for chronic back pain. Can you get the request ready?",
      "assistant_response": "Request details verified for Robert Chen:\n\n- **CPT 72148** \u2013 Lumbar MRI w/o contrast\n- **Dx** M54.5 \u2013 Chronic low back pain\n- **Ordering:** Dr. James Thompson, Orthopedics\n- **Clinical basis:** Failed 6 weeks conservative therapy\n- Insurance and MRN confirmed against the record\n\nNext step is checking the payer's specific requirements against this clinical picture before I build the submission packet \u2014 want me to run that now?",
      "agent_logs": "[PriorAuthorizationAgent] # Prior Authorization Request\n\n> Synthetic demonstration data only. This output is a read-only evidence draft, not an authorization, eligibility, medical-necessity, diagnosis, or treatment decision. A qualified utilization reviewer must verify payer policy and clinical evidence before any submission.\n\nPatient demographics, insurance coverage and clinical documentation verified against the synthetic EHR record. Ready to prepare for submission.\n\n| Detail | Value |\n|---|---|\n| Patient | Robert Chen, DOB 05/22/1965 |\n| MRN | MR-489327 |\n| Insurance | Insurance PPO #XY4829103 |\n| CPT code | 72148 - Lumbar MRI w/o contrast |\n| Provider | Dr. James Thompson (Orthopedics) |\n| Diagnosis | M54.5 - Chronic low back pain (source-coded; no diagnosis added) |\n| Clinical indication | Failed 6 weeks conservative therapy |\n\n**Status:** All patient data verified from the synthetic EHR record.\n**Next:** check payer requirements?",
      "expected_agent": "PriorAuthorizationAgent",
      "must_include": [
        "MR-489327",
        "72148",
        "Dr. James Thompson"
      ],
      "model": "claude-sonnet-5",
      "requested_model": "claude-sonnet-5",
      "passed": true
    },
    {
      "case_id": "PA-06",
      "persona": "Utilization Management Coordinator",
      "onepager_promise": "Pull payer-specific requirements and match them with EHR data",
      "prompt": "Check Robert Chen's payer requirements for the lumbar MRI against his documentation.",
      "assistant_response": "Here's the payer requirements check for Robert Chen's lumbar MRI (CPT 72148):\n\n**All 6 of 6 criteria met** \u2705\n- Clinical notes (last 3 visits) \u2014 Met\n- Conservative therapy (PT x6 weeks + NSAIDs) \u2014 Met\n- Symptom duration (8 weeks, no improvement) \u2014 Met\n- Red flag screening (negative) \u2014 Met\n- Provider NPI verified \u2014 Met\n- Prior imaging documented (none, first study) \u2014 Met\n\nNo missing documentation, and the expected payer turnaround is 24\u201348 hours. This is a strong, complete request on paper \u2014 but a utilization reviewer still needs to confirm this isn't a medical-necessity decision I can make.\n\nWant me to pull together the submission packet next, or check the approval outlook/appeal strategy first?",
      "agent_logs": "[PriorAuthorizationAgent] # Insurance Requirements\n\n> Synthetic demonstration data only. This output is a read-only evidence draft, not an authorization, eligibility, medical-necessity, diagnosis, or treatment decision. A qualified utilization reviewer must verify payer policy and clinical evidence before any submission.\n\nPayer requirements for CPT 72148 matched against Robert Chen's documentation.\n\n| Requirement | Evidence found | Status |\n|---|---|---|\n| Clinical notes | Last 3 office visits attached | Met |\n| Conservative therapy | PT x6 weeks, NSAIDs documented | Met |\n| Symptom duration | 8 weeks, no improvement | Met |\n| Red flag screening | Negative (no fever/trauma/cancer) | Met |\n| Provider NPI | Dr. Thompson #1234567890 | Met |\n| Prior imaging | None on file (first lumbar study) | Met |\n\n**Assessment:**\n- All required criteria met (6 of 6 have matching evidence)\n- No missing documentation\n- Estimated payer turnaround: 24-48 hours (standard review)\n- A utilization reviewer confirms the match; this is not a medical-necessity decision.\n**Next:** prepare the authorization for submission?",
      "expected_agent": "PriorAuthorizationAgent",
      "must_include": [
        "PT x6 weeks",
        "Red flag screening",
        "All required criteria met"
      ],
      "model": "claude-sonnet-5",
      "requested_model": "claude-sonnet-5",
      "passed": true
    },
    {
      "case_id": "PA-07",
      "persona": "Utilization Management Coordinator",
      "onepager_promise": "Submit requests directly to payer portals and send real-time updates",
      "prompt": "Get Robert Chen's lumbar MRI authorization ready to submit and give me the confirmation details.",
      "assistant_response": "Here's the packet for Robert Chen's lumbar MRI \u2014 prepared and ready for a human to submit, but I haven't submitted anything or sent any notifications:\n\n| Detail | Value |\n|---|---|\n| Auth request # | PA-2024-892741 |\n| Prepared | Today at 3:47 PM |\n| Payer reference | Case #4729183 |\n| Review type | Standard (non-urgent) |\n| Expected decision | Within 2 business days |\n| Reviewer | Automated criteria screening |\n\nDrafted (but unsent until someone submits):\n- Patient SMS with tracking link\n- Message to Dr. Thompson\n- Radiology scheduling alert\n\nThis is synthetic demo data \u2014 a utilization reviewer still needs to confirm policy fit and actually click submit in the payer portal. Want me to pull the documentation-strength review or appeal strategy next?",
      "agent_logs": "[PriorAuthorizationAgent] # Submission Packet \u2014 Ready for You to Submit\n\n> Synthetic demonstration data only. This output is a read-only evidence draft, not an authorization, eligibility, medical-necessity, diagnosis, or treatment decision. A qualified utilization reviewer must verify payer policy and clinical evidence before any submission.\n\nThe authorization request is complete and ready for the coordinator to submit in the payer portal.\n\n| Detail | Value |\n|---|---|\n| Auth request # | PA-2024-892741 |\n| Prepared | Today at 3:47 PM |\n| Payer reference | Case #4729183 |\n| Review type | Standard (non-urgent) |\n| Expected decision | Within 2 business days |\n| Reviewer | Automated criteria screening |\n\n**Notifications drafted (sent only when you submit):**\n- Patient: SMS with tracking link\n- Dr. Thompson: Inbox message\n- Radiology: Pending alert for scheduling\n\nNot submitted: no payer submission was made and no notification was sent.\n**Next:** review documentation strength and appeal readiness?",
      "expected_agent": "PriorAuthorizationAgent",
      "must_include": [
        "PA-2024-892741",
        "Case #4729183",
        "Not submitted"
      ],
      "model": "claude-sonnet-5",
      "requested_model": "claude-sonnet-5",
      "passed": true
    },
    {
      "case_id": "PA-08",
      "persona": "Utilization Management Coordinator",
      "onepager_promise": "Flag cases requiring additional documentation and prepare appeal materials proactively",
      "prompt": "How strong is Robert Chen's lumbar MRI request, and what is our appeal strategy if it is denied?",
      "assistant_response": "Here's the evidence pulled by the Prior Authorization agent:\n\n**Strength:** Solid \u2014 comparable cases historically approve ~94%, and Robert's packet checks the key boxes:\n- Documented conservative therapy (PT + NSAIDs)\n- Symptom duration over 6 weeks\n- Clinical notes align with medical-necessity criteria\n- No red flags for inappropriate imaging\n- Complete documentation overall\n\n**If denied, appeal plan:**\n1. Request a peer-to-peer review with a radiologist\n2. Add supplemental functional-impact documentation\n3. Cite the relevant imaging guideline criteria directly\n\nNo prediction or decision is being made here \u2014 this is just the evidence picture to help a reviewer judge strength and plan ahead. Want me to set up tracking so you're alerted as soon as the payer responds?",
      "agent_logs": "[PriorAuthorizationAgent] # Approval Outlook and Appeal Strategy\n\n> Synthetic demonstration data only. This output is a read-only evidence draft, not an authorization, eligibility, medical-necessity, diagnosis, or treatment decision. A qualified utilization reviewer must verify payer policy and clinical evidence before any submission.\n\n**Historical approval rate:** 94% for similar cases (synthetic historical statistic; no prediction is made for this request).\n\n**Documentation strengths:**\n- Conservative therapy well-documented (PT, NSAIDs)\n- Symptom duration >6 weeks\n- Clinical notes support medical necessity criteria\n- No inappropriate imaging red flags\n- Complete documentation package\n\n**If denied - appeal strategy:**\n- Peer-to-peer review with radiologist\n- Additional functional impact documentation\n- Imaging guidelines citation\n\n**Proposed escalation:** alert within 2 hours of the payer decision.\n**Next:** set up tracking and notifications?",
      "expected_agent": "PriorAuthorizationAgent",
      "must_include": [
        "94% for similar cases",
        "Peer-to-peer review with radiologist",
        "Complete documentation package"
      ],
      "model": "claude-sonnet-5",
      "requested_model": "claude-sonnet-5",
      "passed": true
    },
    {
      "case_id": "PA-09",
      "persona": "Utilization Management Coordinator",
      "onepager_promise": "Submit requests directly to payer portals and send real-time updates",
      "prompt": "Set up tracking for Robert Chen's authorization and plan to notify everyone when it is approved.",
      "assistant_response": "Here's the proposed plan for PA-2024-892741 (Robert Chen, Lumbar MRI):\n\n- **Status checks**: every 4 hours\n- **Notifications on approval**: SMS to patient, alert to radiology scheduling, secure message to Dr. Thompson\n- **Escalation**: auto-trigger if no decision in 48 hours\n- **Appeal workflow**: pre-staged in case of denial\n- A Teams post is drafted but not sent\n\nNothing is live \u2014 this is just the plan draft. To actually turn on tracking and fire notifications, a human on the UR team needs to enable it in the actual system. Want me to pull up the full pending-auth portfolio too?",
      "agent_logs": "[PriorAuthorizationAgent] # Tracking and Notification Plan (Proposed)\n\n> Synthetic demonstration data only. This output is a read-only evidence draft, not an authorization, eligibility, medical-necessity, diagnosis, or treatment decision. A qualified utilization reviewer must verify payer policy and clinical evidence before any submission.\n\nProposed monitoring for PA-2024-892741 (Robert Chen, Lumbar MRI), ready for you to switch on:\n\n- Status checks: every 4 hours via portal\n- Patient notification: SMS when approved (includes auth #)\n- Radiology alert: scheduling team notified to book slot\n- Provider update: Dr. Thompson via secure message\n- Escalation: auto-trigger if no decision in 48 hours\n- Appeal workflow: ready if denied\n\n**Tracking dashboard:** Teams channel post drafted (not posted); real-time status updates once enabled; expected decision within 2 business days.\nNothing is scheduled or sent until you enable it.\n**Next:** see all pending prior auths?",
      "expected_agent": "PriorAuthorizationAgent",
      "must_include": [
        "every 4 hours",
        "48 hours",
        "Teams channel post drafted"
      ],
      "model": "claude-sonnet-5",
      "requested_model": "claude-sonnet-5",
      "passed": true
    },
    {
      "case_id": "PA-10",
      "persona": "Utilization Management Coordinator",
      "onepager_promise": "Submit requests directly to payer portals and send real-time updates",
      "prompt": "Show me all pending prior auths and their status.",
      "assistant_response": "Here's your portfolio (synthetic demo data):\n\n| Auth # | Patient | Procedure | Payer | Status |\n|---|---|---|---|---|\n| PA-2024-892741 | Chen, Robert | Lumbar MRI | Insurance | Ready to submit |\n| PA-2024-892655 | Martinez, Ana | Knee arthroscopy | Insurance | Approved |\n| PA-2024-892698 | Thompson, David | Cervical MRI | Insurance | Pending |\n| PA-2024-892712 | Williams, Sarah | PT (20 visits) | Insurance | Under review |\n| PA-2024-891977 | Johnson, Michael | Sleep study | Medicare | **Denied** (appealing) |\n\n**Snapshot:** 3 pending, 91% approval rate this month, avg 2.4 days to decision.\n\nWant me to pull up the denial review on Michael Johnson's case, or check approval odds on one of the pending ones?",
      "agent_logs": "[PriorAuthorizationAgent] # Active Prior Authorizations\n\n> Synthetic demonstration data only. This output is a read-only evidence draft, not an authorization, eligibility, medical-necessity, diagnosis, or treatment decision. A qualified utilization reviewer must verify payer policy and clinical evidence before any submission.\n\n| Auth # | Patient | Procedure | Payer | Status |\n|---|---|---|---|---|\n| PA-2024-892741 | Chen, Robert | Lumbar MRI | Insurance | Ready to submit |\n| PA-2024-892655 | Martinez, Ana | Knee arthroscopy | Insurance | Approved |\n| PA-2024-892698 | Thompson, David | Cervical MRI | Insurance | Pending |\n| PA-2024-892712 | Williams, Sarah | PT (20 visits) | Insurance | Under review |\n| PA-2024-891977 | Johnson, Michael | Sleep study | Medicare | Denied (appealing) |\n\n**Portfolio metrics:**\n- Pending: 3 authorizations\n- Avg approval time: 2.4 days\n- Approval rate: 91% this month\nStatuses are source-recorded for human review, not agent determinations.\n**Next:** check the denied Medicare case?",
      "expected_agent": "PriorAuthorizationAgent",
      "must_include": [
        "Martinez, Ana",
        "Pending: 3 authorizations",
        "91% this month"
      ],
      "model": "claude-sonnet-5",
      "requested_model": "claude-sonnet-5",
      "passed": true
    },
    {
      "case_id": "PA-11",
      "persona": "Utilization Management Coordinator",
      "onepager_promise": "Flag cases requiring additional documentation and prepare appeal materials proactively",
      "prompt": "Why was the Medicare sleep study request denied, and where does the appeal stand?",
      "assistant_response": "Here's the denial breakdown (synthetic demo case, Michael Johnson):\n\n**Why denied:** Insufficient documentation of daytime symptoms \u2014 specifically missing:\n- Epworth Sleepiness Scale score\n- Documentation of work/driving impairment\n- Clear record of a failed CPAP trial\n\n**Appeal status (in progress):**\n- Peer-to-peer review scheduled tomorrow at 2 PM\n- Symptom questionnaire now completed\n- Employer letter on work impact obtained\n- Prior CPAP compliance data retrieved\n\nDecision expected within 5 business days. Note: this is read-only evidence \u2014 a human reviewer owns the actual appeal decision.",
      "agent_logs": "[PriorAuthorizationAgent] # Denial Details - Johnson, Michael - Sleep study\n\n> Synthetic demonstration data only. This output is a read-only evidence draft, not an authorization, eligibility, medical-necessity, diagnosis, or treatment decision. A qualified utilization reviewer must verify payer policy and clinical evidence before any submission.\n\n**Request:** PA-2024-891977, Michael Johnson, Sleep study, Medicare - Denied (appealing)\n**Reason:** Insufficient clinical documentation of daytime symptoms\n\n**Missing elements:**\n- Epworth Sleepiness Scale not in records\n- Work/driving impairment not documented\n- Failed CPAP trial not clearly stated\n\n**Appeal actions recorded:**\n- Peer-to-peer review scheduled - tomorrow 2 PM\n- Additional symptom questionnaire completed\n- Employer letter documenting work issues\n- Prior CPAP compliance data retrieved\n\n**Timeline:** Decision expected within 5 business days\nA qualified reviewer owns the appeal; this summary makes no authorization decision.\n**Next:** return to the Chen authorization?",
      "expected_agent": "PriorAuthorizationAgent",
      "must_include": [
        "Epworth Sleepiness Scale",
        "tomorrow 2 PM",
        "5 business days"
      ],
      "model": "claude-sonnet-5",
      "requested_model": "claude-sonnet-5",
      "passed": true
    }
  ]
}