Prior Authorization

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---
name: 'prior-auth-coworker'
description: 'Prior Auth Review'
measurable_outcome: Execute skill workflow successfully with valid output within 15 minutes.
allowed-tools:
  - read_file
  - run_shell_command
---


# Prior Authorization Coworker

This skill acts as an automated utilization management reviewer. It takes unstructured clinical notes and a procedure code, compares them against internal policy criteria (e.g., conservative therapy failure), and renders a decision.

## When to Use This Skill

*   When a user asks to "review a prior auth request".
*   When checking if a patient qualifies for a specific procedure (e.g., MRI).
*   When you need to generate a structured approval/denial letter justification.

## Core Capabilities

1.  **Policy Matching**: Checks against specific criteria (e.g., "Pain > 6 weeks").
2.  **Trace Generation**: Produces an "Anthropic-style" `<thinking>` trace for auditability.
3.  **Structured Output**: Returns a JSON object with decision, reasoning, and timestamps.
4.  **Microsoft Payer-Side Multi-Agent Review**: Supports Microsoft Agent Framework architecture patterns with four Foundry Hosted Agents for compliance, clinical, coverage, and synthesis review; gate-based decision rubrics; MCP healthcare data access; confidence scoring; audit trails; Azure Container Apps deployment via `azd`; and human-in-the-loop escalation.

## Workflow

1.  **Extract Data**: Parse the clinical note and procedure code from the user's input.
2.  **Execute Review**: Run the coworker script.
3.  **Present Decision**: Output the JSON decision and the reasoning trace.

## Example Usage

**User**: "Check if this patient qualifies for an MRI of the Lumbar Spine: Patient has had back pain for 2 months, tried PT but it didn't work."

**Agent Action**:
```bash
python3 Skills/Clinical/Prior_Authorization/anthropic_coworker.py --code "MRI-L-SPINE" --note "Patient has back pain > 2 months. Failed PT."
```

## Supported Policies

*   `MRI-L-SPINE` (Lumbar Spine MRI)

## References

*   https://github.com/microsoft/Prior-Authorization-Multi-Agent-Solution-Accelerator


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