prior-authorization-letter
GitHub用于撰写具有说服力的预授权或医疗必要性信函，协助保险公司审核。支持常规申请及拒赔申诉场景，结构包含患者信息、临床依据、既往治疗史及明确诉求。强调基于真实病历生成，严禁虚构数据，需由医生最终审核签署。
触发场景
安装
npx skills add mohitagw15856/pm-claude-skills --skill prior-authorization-letter -g -y
SKILL.md
Frontmatter
{
"name": "prior-authorization-letter",
"description": "Write a persuasive prior-authorization \/ medical-necessity letter to an insurer. Use when asked to write a prior authorization letter, a letter of medical necessity, or to appeal a denied treatment\/medication\/procedure. Produces a structured letter — patient and request, clinical justification tied to guidelines, treatments tried, and the specific approval asked for — ready for clinician review and signature."
}
Prior Authorization Letter Skill
A prior-auth or medical-necessity letter succeeds when it connects this patient's clinical facts to the insurer's coverage criteria — clearly, with evidence, and with the exact request spelled out. This skill structures that argument so the reviewer can approve it quickly, and so an appeal addresses the stated denial reason head-on.
Clinical-safety note: this is a documentation aid, not medical advice. The clinical justification must reflect the treating clinician's judgement and the patient's actual record; the clinician must review, verify, and sign before submission. Do not invent diagnoses, codes, history, or evidence.
Working from a brief
Given the treatment and a diagnosis, produce the full letter anyway — structure the argument and insert the standard elements, marking patient-specific facts (codes, dates, prior treatments) to be confirmed rather than inventing them. For an appeal, infer and directly rebut the likely denial reason if it's stated. Never fabricate clinical history or citations.
Required Inputs
Ask for these only if they aren't already provided (else mark to confirm):
- Patient & policy — patient identifiers and insurance/policy details (as provided).
- The request — the specific medication/procedure/service, with codes (CPT/HCPCS/ICD-10) if available.
- Clinical justification — diagnosis, severity, relevant history, and why this treatment is medically necessary.
- Prior treatments — what's been tried and failed/contraindicated (step-therapy history).
- If an appeal — the denial reason given by the insurer.
Output Format
Letter of Medical Necessity / Prior Authorization
- Header — date, insurer/UM department, patient name, policy/member ID, and the requesting clinician.
- Re: the specific request and relevant codes (diagnosis + procedure/drug).
- 1. Request — one sentence stating exactly what authorization is sought.
- 2. Patient clinical picture — diagnosis, severity, functional impact, and pertinent history (verified facts only).
- 3. Medical necessity — why this treatment is necessary for this patient, tied to recognised clinical guidelines/evidence and the insurer's likely coverage criteria.
- 4. Prior treatments tried — the step-therapy history: what was tried, the outcome, and why alternatives are unsuitable.
- 5. Requested action — the explicit approval asked for, and the clinician's offer to provide records or discuss.
- Signature block — clinician name, credentials, contact.
For an appeal, add a section that quotes the denial reason and rebuts it specifically.
Close with a list of facts to confirm before sending and a clinician-sign-off reminder.
Quality Checks
- The exact request (with codes where available) is stated unambiguously up front
- Medical necessity is tied to recognised guidelines/criteria, not just assertion
- Step-therapy / prior-treatment history is documented (what was tried and why it failed/is unsuitable)
- For an appeal, the specific denial reason is quoted and directly rebutted
- No clinical fact, code, or citation is invented — unverified items are flagged to confirm
- The letter is ready for clinician review and signature (signature block included)
Anti-Patterns
- Do not invent diagnoses, codes, dates, prior treatments, or evidence to strengthen the case
- Do not be vague about the request — name the exact service/drug and codes
- Do not ignore the stated denial reason in an appeal — address it head-on
- Do not present this as medical advice or submit without clinician review and signature
- Do not pad with generic boilerplate that buries the patient-specific justification
Based On
Utilization-management correspondence practice — medical-necessity argumentation tied to coverage criteria, step-therapy documentation, and targeted appeals.
版本历史
- a38bc30 当前 2026-07-05 11:21
