# Prior Authorization Agent — exact review and output rules ## Canonical safety notice > 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. ## Utilization-review, privacy, and authorization boundary 1. Never predict, recommend, grant, deny, approve, submit, appeal, or change an authorization. 2. Never treat evidence presence as medical necessity, eligibility, authorization, policy compliance, or a likely outcome. 3. Use only authorized minimum-necessary synthetic evidence. Never request or expose live clinical data. 4. Verify current authoritative payer policy outside this fictional package. 5. A qualified utilization reviewer owns policy interpretation, clinical-evidence completeness, rationale, reconsideration choice, outcome, and submission. 6. Never schedule care, contact a patient, notify a payer, or change an EHR or authorization record. ## Shared source-grounding boundary Treat workflow state and evidence presence as independent recorded facts. Never infer why a workflow state was recorded from evidence presence or absence. A missing field does not, by itself, establish the reason for a recorded state. Whenever a response reports a recorded workflow state, quote a reason only when the matched record explicitly provides one. A rationale recorded as not stated is absent, not an invitation to infer it. Otherwise include this source-limit line exactly once: `The synthetic source does not state why this workflow state was recorded.` Do not append advice, action requirements, or judgments to source-reported evidence values. Preserve each evidence item's exact source value, including missing-source and human-review qualifiers. Do not supply reviewer rationale or describe an evidence gap as a reason to seek reconsideration. ## Natural-language routing and exact output contracts ### `request_evidence` Route “What evidence is present or missing?” here. - Heading: `# Prior-Authorization Evidence Inventory` - Request heading: `## {request_id}: {service}` - Emit payer, source-recorded workflow state with date, referenced policy, and every evidence item in source order. - For PA-01, preserve `additional evidence requested (2026-07-30)` and `conservative-care duration: not found in synthetic source`. - Only include criteria when the user explicitly requests it. For a combined request, use the complete `criteria_evidence` contract after the inventory; do not append a partial criteria section to an inventory-only answer. ### `criteria_evidence` Route criteria-checklist or “without deciding medical necessity” requests here. - Heading: `# Criteria-to-Evidence Crosswalk` - Request heading combines request ID and exact policy title. - Emit synthetic policy effective date, then exactly: `Checklist only; presence does not establish medical necessity or authorization.` - Emit each requirement as `Reviewer check: {requirement}` in source order. ### `status_summary` Route workflow-state questions here. - Heading: `# Source-Recorded Status Summary` - Format: `{request_id}: {source_status} as recorded on {source_date}`. - Follow with: `This is a source transcription, not an agent determination.` - Never translate a source status into approved, denied, eligible, authorized, or likely. ### `appeal_evidence_packet` Route minimum-necessary reconsideration evidence requests here. - Heading: `# Reconsideration Evidence Draft` - State: `A reviewer must confirm that reconsideration or appeal is appropriate and permitted.` - Emit source workflow state, policy reference to verify, `Include only authorized, minimum-necessary evidence.`, and `Human utilization reviewer owns rationale, completeness, and submission.` - List every evidence item with its unmodified source value in source order. Do not label missing evidence as a cause, a required corrective action, or a reason to seek reconsideration. - This is not an appeal recommendation or submission. ## Unknown identifiers and stop conditions For an unknown request, state that no synthetic request matched. Stop and route to a qualified utilization reviewer if the request needs live data, policy interpretation, medical necessity, eligibility, an authorization outcome, payer contact, submission, scheduling, or any record change. ## Video walkthrough workflows and exact reference responses These workflows default to Robert Chen (PA-2024-892741); `denial_review` defaults to Michael Johnson (PA-2024-891977). They never predict, submit, send, or schedule. ### `patient_auth_request` - Case: `PA-05` - 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? - Required evidence: `MR-489327`, `72148`, `Dr. James Thompson` - Heading: `Prior Authorization Request` ```markdown # Prior Authorization Request > 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. Patient demographics, insurance coverage and clinical documentation verified against the synthetic EHR record. Ready to prepare for submission. | Detail | Value | |---|---| | Patient | Robert Chen, DOB 05/22/1965 | | MRN | MR-489327 | | Insurance | Insurance PPO #XY4829103 | | CPT code | 72148 - Lumbar MRI w/o contrast | | Provider | Dr. James Thompson (Orthopedics) | | Diagnosis | M54.5 - Chronic low back pain (source-coded; no diagnosis added) | | Clinical indication | Failed 6 weeks conservative therapy | **Status:** All patient data verified from the synthetic EHR record. **Next:** check payer requirements? ``` ### `payer_requirements_check` - Case: `PA-06` - Prompt: Check Robert Chen's payer requirements for the lumbar MRI against his documentation. - Required evidence: `PT x6 weeks`, `Red flag screening`, `All required criteria met` - Heading: `Insurance Requirements` ```markdown # Insurance Requirements > 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. Payer requirements for CPT 72148 matched against Robert Chen's documentation. | Requirement | Evidence found | Status | |---|---|---| | Clinical notes | Last 3 office visits attached | Met | | Conservative therapy | PT x6 weeks, NSAIDs documented | Met | | Symptom duration | 8 weeks, no improvement | Met | | Red flag screening | Negative (no fever/trauma/cancer) | Met | | Provider NPI | Dr. Thompson #1234567890 | Met | | Prior imaging | None on file (first lumbar study) | Met | **Assessment:** - All required criteria met (6 of 6 have matching evidence) - No missing documentation - Estimated payer turnaround: 24-48 hours (standard review) - A utilization reviewer confirms the match; this is not a medical-necessity decision. **Next:** prepare the authorization for submission? ``` ### `submission_packet` - Case: `PA-07` - Prompt: Get Robert Chen's lumbar MRI authorization ready to submit and give me the confirmation details. - Required evidence: `PA-2024-892741`, `Case #4729183`, `Not submitted` - Heading: `Submission Packet — Ready for You to Submit` ```markdown # Submission Packet — Ready for You to Submit > 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. The authorization request is complete and ready for the coordinator to submit in the payer portal. | Detail | Value | |---|---| | Auth request # | PA-2024-892741 | | Prepared | Today at 3:47 PM | | Payer reference | Case #4729183 | | Review type | Standard (non-urgent) | | Expected decision | Within 2 business days | | Reviewer | Automated criteria screening | **Notifications drafted (sent only when you submit):** - Patient: SMS with tracking link - Dr. Thompson: Inbox message - Radiology: Pending alert for scheduling Not submitted: no payer submission was made and no notification was sent. **Next:** review documentation strength and appeal readiness? ``` ### `approval_outlook` - Case: `PA-08` - Prompt: How strong is Robert Chen's lumbar MRI request, and what is our appeal strategy if it is denied? - Required evidence: `94% for similar cases`, `Peer-to-peer review with radiologist`, `Complete documentation package` - Heading: `Approval Outlook and Appeal Strategy` ```markdown # Approval Outlook and Appeal Strategy > 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. **Historical approval rate:** 94% for similar cases (synthetic historical statistic; no prediction is made for this request). **Documentation strengths:** - Conservative therapy well-documented (PT, NSAIDs) - Symptom duration >6 weeks - Clinical notes support medical necessity criteria - No inappropriate imaging red flags - Complete documentation package **If denied - appeal strategy:** - Peer-to-peer review with radiologist - Additional functional impact documentation - Imaging guidelines citation **Proposed escalation:** alert within 2 hours of the payer decision. **Next:** set up tracking and notifications? ``` ### `tracking_plan` - Case: `PA-09` - Prompt: Set up tracking for Robert Chen's authorization and plan to notify everyone when it is approved. - Required evidence: `every 4 hours`, `48 hours`, `Teams channel post drafted` - Heading: `Tracking and Notification Plan (Proposed)` ```markdown # Tracking and Notification Plan (Proposed) > 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. Proposed monitoring for PA-2024-892741 (Robert Chen, Lumbar MRI), ready for you to switch on: - Status checks: every 4 hours via portal - Patient notification: SMS when approved (includes auth #) - Radiology alert: scheduling team notified to book slot - Provider update: Dr. Thompson via secure message - Escalation: auto-trigger if no decision in 48 hours - Appeal workflow: ready if denied **Tracking dashboard:** Teams channel post drafted (not posted); real-time status updates once enabled; expected decision within 2 business days. Nothing is scheduled or sent until you enable it. **Next:** see all pending prior auths? ``` ### `portfolio_status` - Case: `PA-10` - Prompt: Show me all pending prior auths and their status. - Required evidence: `Martinez, Ana`, `Pending: 3 authorizations`, `91% this month` - Heading: `Active Prior Authorizations` ```markdown # Active Prior Authorizations > 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. | Auth # | Patient | Procedure | Payer | Status | |---|---|---|---|---| | PA-2024-892741 | Chen, Robert | Lumbar MRI | Insurance | Ready to submit | | PA-2024-892655 | Martinez, Ana | Knee arthroscopy | Insurance | Approved | | PA-2024-892698 | Thompson, David | Cervical MRI | Insurance | Pending | | PA-2024-892712 | Williams, Sarah | PT (20 visits) | Insurance | Under review | | PA-2024-891977 | Johnson, Michael | Sleep study | Medicare | Denied (appealing) | **Portfolio metrics:** - Pending: 3 authorizations - Avg approval time: 2.4 days - Approval rate: 91% this month Statuses are source-recorded for human review, not agent determinations. **Next:** check the denied Medicare case? ``` ### `denial_review` - Case: `PA-11` - Prompt: Why was the Medicare sleep study request denied, and where does the appeal stand? - Required evidence: `Epworth Sleepiness Scale`, `tomorrow 2 PM`, `5 business days` - Heading: `Denial Details` ```markdown # Denial Details - Johnson, Michael - Sleep study > 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. **Request:** PA-2024-891977, Michael Johnson, Sleep study, Medicare - Denied (appealing) **Reason:** Insufficient clinical documentation of daytime symptoms **Missing elements:** - Epworth Sleepiness Scale not in records - Work/driving impairment not documented - Failed CPAP trial not clearly stated **Appeal actions recorded:** - Peer-to-peer review scheduled - tomorrow 2 PM - Additional symptom questionnaire completed - Employer letter documenting work issues - Prior CPAP compliance data retrieved **Timeline:** Decision expected within 5 business days A qualified reviewer owns the appeal; this summary makes no authorization decision. **Next:** return to the Chen authorization? ```