# Usage: curl -sSL https://seed.show/healthcare.prior.auth | bash -s <install-path>
# <install-path> is the directory where the file should land.

set -euo pipefail
[ -z "${1:-}" ] && {
  echo "install requires a path: curl -sSL https://seed.show/healthcare.prior.auth | bash -s <install-path>" >&2
  exit 1
}
TARGET="$1"
mkdir -p "$TARGET"
DEST="$TARGET/seed-fold.RTAUAG.folded.md"

cat > "$DEST" <<'PORTDOWN_B6277D40'
<!--
This is a `.folded.md` archive — a directory packed into one markdown
file. The markers below are load-bearing; don't edit them directly.

To unpack (requires bash — if you have no shell, tell the user):
  1. curl -sSLf https://fold.dom.vin/skill | bash -s <INSTALL_DIR>
  2. <INSTALL_DIR>/fold/scripts/unfold <this-file>
     (or: unfold <this-file>  if fold/scripts is on your PATH)
-->

---
fold: true
marker: 7f8407
at: 2026-05-07T16:16:08Z
root: seed-pack.14LPTf
---

<!--fold:7f8407@file path="README.md" mode="644"-->
# healthcare.prior.auth

Prior authorization context for agents. What PA is actually doing, why payers and providers have genuinely opposed interests, and what agents consistently get wrong.

## What level to work at

CMS, individual payers, and clinical criteria vendors publish the canonical rules. This bundle is the orientation layer: the mental model of how a PA moves, the provider/payer tension that shapes every step, and which sources to fetch before touching a submission or appeal.

PA requirement lists and payer-specific clinical criteria change continuously — on January 1 annually with plan renewals and mid-year with plan amendments. Never treat any cached PA requirement as current. Always verify against the payer's live portal or current benefit grid.

## What agents must never do

**Never imply a prior authorization will be approved.** Payer decisions are final subject to the applicable appeal process; they are not predictable from documentation quality alone. Agents may describe what complete, criteria-aligned documentation looks like. Agents may not represent that approval is likely or expected. The clinical decision to authorize belongs to the payer's medical director, not to the documentation or to the agent.

## What prior authorization is actually doing

Prior authorization is a utilization management mechanism. Its official purpose is ensuring that treatments are medically necessary, evidence-based, and covered before they are provided. Its actual function depends entirely on which side of the transaction you are on.

**From the payer's perspective:** PA is a cost-control gate. Payers use it to enforce clinical coverage policies, deflect inappropriate utilization, and shift financial risk back to providers and patients when care falls outside defined criteria. It is also a volume filter — many services are denied or abandoned at the submission stage before a clinical reviewer ever sees them, which reduces costs without requiring a formal decision. Medical necessity criteria (InterQual, MCG) give payers standardized, defensible grounds for denial.

**From the provider's perspective:** PA is an administrative tax on clinical care. Completing a PA request for a single service can take 30–60 minutes of staff time. A practice submitting dozens per week dedicates staff full-time to a function that produces no clinical value. Delays are clinically consequential: a patient waiting for PA approval for chemotherapy, insulin, or an MRI is not getting care. The AMA surveys consistently show that 90%+ of physicians report PA delays causing adverse outcomes; roughly a third lead to hospitalizations or serious events.

These perspectives are genuinely in tension. They are not a misunderstanding. The payer's interest in cost control and the provider's interest in timely care are structurally opposed at the point where PA operates.

## The PA lifecycle

**Benefit verification** — Before submission, the provider must confirm the patient has active coverage, that the service is a covered benefit under the plan, and that PA is required. Missing this step is the most common waste-producing error: completing a full PA submission for a service that is either not covered or does not require PA. Eligibility and benefits verification is a prerequisite, not a parallel step.

**PA requirement determination** — Not every service requires PA, and PA requirements vary by payer, plan, and service type. The same CPT code may require PA on one commercial plan and not on another from the same insurer. Requirements change on January 1 annually and mid-year with plan changes. There is no authoritative central registry; this must be confirmed against the specific plan's current formulary or benefit grid.

**Clinical documentation assembly** — PA approval is not based on the provider's belief that the service is necessary; it is based on whether the submitted documentation satisfies the payer's clinical criteria. InterQual and MCG (Milliman) are the two dominant clinical decision support tools. Payers license them and use them as the de facto standard for what "medically necessary" means. The provider must understand the specific criteria being applied — not just that the patient needs the service, but that the documentation addresses each required element of the relevant InterQual or MCG guideline.

**Submission** — PA requests are submitted via EDI 278 (the X12 electronic transaction) or through the payer's provider portal. Most commercial payers and Medicaid plans require portal submission; Medicare Advantage plans vary. The submission must include: diagnosis codes, procedure codes, treating provider NPI, referring provider NPI (if applicable), dates of service, and supporting clinical documentation. Missing any of these triggers an automatic rejection, not a denial — rejections don't start the appeal clock.

**Status tracking** — After submission, the PA request is either approved, pended for medical review, or denied. Pended requests require follow-up; many providers let pended requests age out without response, which functions as a de facto denial. CMS's 2024 final rule (CMS-0057-F) mandates decision timelines: 72 hours for urgent/expedited PA, 7 days for standard PA (for Medicare Advantage and certain other payers by 2026).

**Approval** — Approved PAs have authorization numbers with defined service windows (quantity, date range). The authorization number must appear on the claim. PA approval does not guarantee payment — coverage, eligibility, and benefit limits are still evaluated at adjudication.

**Denial response** — A denial is not the end. Providers have several escalation paths (see workflow.md). Conflating denial with non-coverage is the most expensive mistake in PA management: many denials are reversible on appeal, particularly initial administrative denials based on missing documentation.

**Expedited / urgent PA** — When delay would seriously jeopardize the patient's life or health, the provider can request an expedited review. CMS mandates a 24-hour turnaround for expedited inpatient PA (72 hours under the 2024 rule for MA plans). Expedited requests require documented clinical urgency — the provider must affirmatively establish that the standard timeline creates clinical risk.

## The payer's criteria and the clinical guidelines are different documents

This distinction matters more than almost anything else in PA. A clinical guideline (e.g., ACR Appropriateness Criteria for imaging, NCCN guidelines for oncology) defines what is clinically appropriate based on evidence. A payer's coverage determination policy defines what the payer will authorize based on its contracted criteria set — typically InterQual or MCG, but sometimes proprietary.

These documents can diverge. A service can be clinically appropriate by ACR or NCCN standards and still be denied under the payer's criteria because the submitted documentation didn't address the specific elements in the applicable InterQual or MCG guideline. Conversely, a service can meet payer criteria without being the best clinical option.

Agents building or assisting PA workflows must operate on the payer's criteria, not on clinical guidelines. Clinical guidelines support the case; payer criteria determine the outcome. Submitting documentation that establishes clinical appropriateness without addressing payer criteria is the most common cause of initial medical necessity denials. Locate the payer's applicable coverage policy or criteria set (published on the provider portal) before assembling documentation.

## What agents get wrong

**Submitting PA without verifying coverage first.** PA is irrelevant if the service isn't covered. Agents building PA submission workflows often skip benefit verification and proceed directly to PA, producing approved authorizations for services the plan won't pay. Coverage verification and PA determination are two separate steps; neither substitutes for the other.

**Missing payer-specific clinical criteria.** "Medically necessary" is not an objective standard — it is defined by the payer's clinical coverage policy, which is typically operationalized via an InterQual or MCG level of care guideline. Submitting documentation that establishes general medical necessity without addressing the specific criteria in the applicable guideline is the most common reason for initial medical denials. The agent must know which criteria set the payer uses, which criteria apply to the specific service, and which documentation elements address each criterion.

**Conflating denial with non-coverage.** Initial denials — especially administrative denials (missing information, wrong format, untimely submission) and level-of-care denials — are frequently reversible. MCG and InterQual criteria have appeal pathways; peer-to-peer review (treating physician calls the payer's medical director) overturns denials at a materially higher rate than written appeals alone. Treating a denial as final closes off paths the provider has a legal right to pursue.

**Missing the appeal window.** PA denial appeals have hard deadlines: typically 30–60 days from the denial date. For expedited appeals, it may be 72 hours. These windows vary by payer and by plan type (commercial, Medicare Advantage, Medicaid managed care). Missing the appeal window extinguishes the right permanently — it is the PA equivalent of timely filing. Agents rarely surface these deadlines proactively.

**Treating PA approval as a payment guarantee.** Authorization means the payer agreed, at that moment, that the service was medically necessary under the benefit. It does not guarantee payment. At adjudication, the payer will also evaluate: current eligibility, remaining benefits, coordination of benefits with another payer, and whether the claim was submitted correctly. Providers who assume approved PA = paid claim skip downstream claim validation and are surprised by denials at the claim level.

**Not distinguishing rejection from denial.** A rejection means the PA request could not be processed — it was technically incomplete, missing required data elements, or submitted to the wrong entity. A rejection does not start the appeal clock and does not result in a denial letter. A denial means the PA request was received and a decision was made to not authorize the service. The response to each is completely different; conflating them causes providers to appeal rejections (which have no appeal path) or miss denials (which do).

**AI-specific failure modes:**

**Hallucinating payer criteria.** Models trained on general medical literature will confidently describe InterQual or MCG criteria that do not match the payer's current, licensed version. PA criteria are versioned annually; the operative criteria for a given service on a given plan date are the payer's contracted version, not any publicly available summary. Never generate specific criteria elements from training data — locate and read the actual payer coverage policy.

**Fabricating authorization numbers or decision outcomes.** Agents that generate draft PA submissions as structured data sometimes propagate fabricated auth numbers or approval statuses into downstream workflows. Any authorization number must come from a real payer response, not from model output. Any approval status must be verified against the payer's live portal or 278 response.

**Applying the wrong clinical criteria set.** The same procedure code may be evaluated under different criteria depending on the clinical context — an MRI may fall under a musculoskeletal guideline or a neurological guideline depending on the diagnosis code. Agents that look up criteria by CPT code alone, without the diagnosis context, will retrieve the wrong guideline and assemble documentation against criteria the payer isn't applying.

**Overstating certainty about approval likelihood.** LLMs are pattern-matchers on submitted documentation. Payer decisions depend on the payer's specific criteria version, the medical director's interpretation, and internal audit targets that are not in any training corpus. An agent that tells a provider "this documentation should be sufficient for approval" is making a clinical coverage determination it has no basis to make. Surface what the documentation does and doesn't address relative to the stated criteria; never predict the outcome.

## What AI is changing

**CMS-0057-F FHIR PA API mandate (effective January 2026).** The 2024 CMS Interoperability and Prior Authorization Final Rule requires Medicare Advantage, Medicaid, CHIP, and ACA marketplace plans to implement three FHIR-based PA APIs: Coverage Requirements Discovery (CRD) for real-time PA requirement lookup at the point of care; Documentation Templates and Rules (DTR) for electronic delivery of payer-specific PA forms and criteria to the provider's EHR; and Prior Authorization Support (PAS) for FHIR-based PA submission and response. These replace or supplement EDI 278 for in-scope payers. Agents building PA automation for these plan types should design to the Da Vinci FHIR Implementation Guides (CRD, DTR, PAS), not just EDI 278. The operational deadline is January 1, 2026.

**AI-assisted PA submission.** Multiple vendors (Cohere Health, Infinitus, Olive, others) now offer AI-assisted PA submission that prepopulates requests from EHR data, checks documentation completeness against criteria, and routes submissions. The practical implication for agents: the submission step is increasingly semi-automated, which shifts the error surface to documentation gap identification (pre-submission) and denial triage (post-decision). Agents are most useful where the criteria interpretation happens, not at the form-filling layer.

**Prior auth gold carding.** Gold carding exempts high-approval providers from routine PA requirements for specific services. Texas was the first state to mandate gold carding (2021); several others have followed or are considering it. CMS's 2024 reporting requirements for payers will produce the approval-rate data needed to operationalize gold carding at scale. For agents: gold carding reduces PA volume for qualified providers but doesn't change the underlying criteria — it changes who is subject to them. Gold carding status is plan-specific and must be confirmed against each payer's current program.

**What stays human.** Clinical documentation judgment — deciding which findings to include, how to frame a clinical narrative, and whether the record adequately supports the medical necessity determination — requires the treating provider's interpretation and remains outside what agents should do autonomously. Peer-to-peer review is a physician-to-physician clinical conversation; agents can prepare the treating physician but cannot conduct the review. Appeals strategy — deciding when to appeal on medical necessity grounds versus policy grounds, when to pursue external review, and what clinical literature strengthens the case — requires knowledge of the specific denial reason, the payer's history on similar appeals, and the clinical merits of the case. These are judgment calls with legal and clinical consequences; agents surface information and draft arguments, but the strategy belongs to the provider and their billing team.
<!--fold:7f8407@file path="sources.md" mode="644"-->
# sources

Fetch these at task time. Ordered by importance.

1. CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) — the 2024 rule mandating FHIR-based PA APIs for Medicare Advantage, Medicaid, CHIP, and ACA plans by January 2026. Covers decision timelines, reason-for-denial requirements, and the FHIR implementation mandate:
   https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f

2. AMA Prior Authorization Reform — AMA's policy and advocacy hub for PA. Includes the annual PA physician survey, the AMA/AHIP consensus principles, and the "Gold Carding" framework (exempting high-approval providers from routine PA):
   https://www.ama-assn.org/practice-management/prior-authorization

3. Da Vinci Prior Authorization Support (PAS) FHIR Implementation Guide — the HL7 FHIR IG that defines the API specification CMS-0057-F is built on. Specifies CRD (Coverage Requirements Discovery), DTR (Documentation Templates and Rules), and PAS transactions:
   https://hl7.org/fhir/us/davinci-pas/

4. InterQual clinical criteria overview — Change Healthcare's (now Optum's) InterQual evidence-based clinical criteria. Most commercial payers and Medicare Advantage plans use InterQual as their level-of-care determination tool. Public overview and product description:
   https://www.optum.com/business/solutions/government/health-plans/clinical-intelligence/interqual-criteria.html

5. MCG (Milliman Care Guidelines) overview — the other dominant clinical criteria vendor; widely used by Medicaid managed care and some commercial plans. Overview of evidence-based care guidelines and utilization management application:
   https://www.mcg.com/care-guidelines/

6. CAQH CORE Prior Authorization Operating Rules — the CAQH Committee on Operating Rules for Information Exchange. Defines the operating rules that complement EDI 278 transactions, including required data elements, response timeframes, and attachment standards:
   https://www.caqh.org/core/prior-authorization

7. X12 278 Health Care Services Review — the EDI transaction standard for PA requests and responses. The 278 Request/Response pair is the electronic standard for non-portal PA submission:
   https://x12.org/products/transaction-sets/278-health-care-services-review

8. CMS Medicare Advantage Prior Authorization and Step Therapy Final Rule — 2023 rule establishing patient protections for MA plan PA requirements, including the prohibition on using PA to circumvent the basic benefit package:
   https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-prior-authorization-and-step-therapy-final-rule-fact-sheet
<!--fold:7f8407@file path="workflow.md" mode="644"-->
# workflow

The prior authorization lifecycle as a decision framework. Each stage has explicit information requirements and exit criteria — the workflow does not advance until those are met. Skipping a stage doesn't save time; it creates rework downstream that takes longer to resolve than the skipped stage would have.

## The workflow

### Benefit verification (prerequisite — before anything else)

**Goal:** Confirm the patient has active coverage, the service is a covered benefit under the plan, and PA is actually required. This is not step one of PA — it is the gate before PA begins.

Decision criteria before proceeding:
- Is the patient's coverage active on the date of service?
- Is the service a covered benefit under the specific plan (not just the payer generally)?
- Does this plan require PA for this service, at this facility, by this provider type?
- Is there a deductible, coinsurance, or coverage limit that affects the clinical recommendation?

What to gather:
- Patient insurance card: payer name, plan type (commercial, Medicare Advantage, Medicaid managed care), group number, member ID
- Payer eligibility response (EDI 270/271 or portal): active coverage dates, plan type, benefit summary, PA requirements for the service
- CPT/HCPCS code and diagnosis code for the planned service — PA requirements are code-specific, not service-category-specific

Hard dependency: If the service is not a covered benefit, PA approval is irrelevant — the claim will deny at adjudication regardless of authorization. Coverage verification and PA determination are two separate lookups; one does not substitute for the other.

Escalate if: Coverage is inactive, the service requires prior authorization but benefit verification returns insufficient detail, or the plan is a carve-out (behavioral health, pharmacy, DME) requiring verification with a separate managed care organization.

---

### PA requirement determination (confirm PA is needed and scope it)

**Goal:** Determine whether PA is required for the specific service under the specific plan, and if so, identify the correct PA pathway and submission entity.

Decision criteria:
- Does the plan require PA for this CPT/HCPCS code? (Requirements vary by code, facility type, and provider specialty — the same code may require PA for an outpatient setting but not inpatient, or vice versa)
- Who administers PA for this service? (Medical, behavioral health, pharmacy, and DME PA may route to different entities even within the same payer)
- Is there a step therapy requirement before this service will be authorized? (e.g., must document failure of a first-line medication before requesting the target drug)
- Is this a site-of-care substitution situation? (Some payers require PA for hospital-based outpatient services but not for the identical service in an independent clinic)

What to gather:
- Current PA requirements from the payer (call the provider relations line or check the online provider portal — PA requirements change January 1 annually and mid-year with plan amendments; prior knowledge is not reliable)
- The correct submission pathway: EDI 278, payer web portal, or phone-only (phone PA is common for urgent/expedited requests and for some Medicaid managed care plans)
- The PA contact for the specific service type if it differs from the main provider services line

Escalate if: The payer cannot confirm PA requirements definitively, or the service has been recently added to or removed from the PA-required list.

---

### Clinical documentation assembly (before submission)

**Goal:** Assemble documentation that satisfies the payer's clinical criteria for medical necessity — not documentation that establishes general clinical need, but documentation that addresses each required element of the applicable criteria set.

Decision criteria before assembling documentation:
- Which clinical criteria set does this payer use for this service? (InterQual or MCG are the two dominant vendors; some payers use proprietary criteria; most publish their coverage determination policies on their provider portal)
- Which specific guideline within that criteria set applies? (e.g., for an MRI of the lumbar spine: InterQual has a specific lumbar spine imaging guideline with defined inclusion criteria — documenting "back pain" is not sufficient; the guideline requires specific physical findings, conservative treatment history, and red flag symptom documentation)
- Does the documentation in the patient's record currently meet those criteria, or are there gaps that the treating provider needs to address?

What to gather:
- Applicable clinical coverage policy or criteria set (download from the payer's provider portal or clinical policy library)
- Clinical documentation: office notes, physical exam findings, imaging reports, lab results, specialist consultations, prior treatment history including failed conservative measures
- Referring provider documentation if a referral is required
- Any required prior authorization forms (some payers have mandatory PA request forms for specific services)

Hard dependency: Submitting a PA request without confirming which criteria apply and verifying that the documentation addresses each criterion is the most common cause of initial medical necessity denials. The documentation doesn't need to be perfect — it needs to address the specific elements the criteria set requires.

---

### Submission (EDI 278 or payer portal)

**Goal:** Transmit a complete, technically valid PA request that will be accepted (not rejected) by the payer and routed to clinical review.

Decision criteria before submitting:
- Is all required data present? (Missing any required element produces a rejection, not a denial — see below)
- Is the PA being submitted to the correct entity and via the correct channel?
- For urgent/expedited PA: is there documentation of clinical urgency that meets the payer's expedited review criteria?

What to submit:
- Diagnosis code(s) — ICD-10-CM, to the highest level of specificity required by the plan
- Procedure code(s) — CPT or HCPCS, with modifiers if required
- Treating provider NPI, specialty, and tax ID
- Referring provider NPI if a referral is required
- Requesting provider NPI if different from treating (common in hospital-based requests)
- Dates of service or service period
- Quantity (number of units, visits, or services requested)
- Supporting clinical documentation — attached to the request (portal) or submitted with the 278 transaction (EDI)

Rejection vs. denial distinction (critical): A rejection means the request could not be processed — it was technically incomplete, submitted to the wrong entity, or failed format validation. Rejections do not start the appeal clock. They must be corrected and resubmitted. A denial means the request was received and processed, and the payer decided not to authorize. Denials start the appeal clock. Agents that conflate these will either miss the appeal window (if they treat a rejection as a denial and wait for appeal resolution) or waste time appealing something that has no appeal path (if they treat a rejection as a denial and initiate appeal).

Expedited/urgent PA: When delay would seriously jeopardize life or health, document clinical urgency explicitly in the request and mark it as expedited. CMS mandates 72-hour turnaround for urgent MA plan PA requests (24 hours for expedited inpatient review under existing rules). Expedited requests without documented urgency will be downgraded to standard review.

---

### Status tracking (post-submission)

**Goal:** Know the current state of every submitted PA request and act on pended requests before they age out.

Decision criteria after submission:
- Has the request been received and assigned a reference number? (No reference number = not received; resubmit)
- Is the request approved, pended for medical review, or denied?
- If pended: what additional information has the payer requested, and what is the response deadline?

What to monitor:
- Payer portal or EDI 277 (Health Care Claim Acknowledgment) for status updates
- Pended request queues — many payers will age out pended requests without notification if the provider doesn't respond to information requests within 5–10 business days
- Decision timelines: CMS-0057-F mandates 72-hour urgent / 7-day standard for Medicare Advantage and certain other payers by January 2026; current regulatory timelines vary by plan type and state

Hard dependency: Pended requests require active follow-up. A PA request sitting in "pending" status without provider response is functionally a denial in progress. Agents must surface pending requests with response deadlines, not just approved and denied requests.

---

### Approval (authorization management)

**Goal:** Capture the authorization details and confirm they match what was requested before the service is rendered.

What to capture on approval:
- Authorization number (required on the claim — missing auth number causes claim denial even for an authorized service)
- Authorized service description: confirm the authorized CPT/HCPCS code matches what was requested
- Authorized quantity: units, visits, or service count
- Authorization date range: services must be rendered within the approved window
- Authorized place of service and provider: confirm the rendering provider and facility match what was authorized (PA issued for one provider or facility does not cover a different one)

PA approval does not guarantee payment. At adjudication, the payer will separately evaluate: current eligibility, remaining benefit limits, coordination of benefits with another payer, and whether the claim was submitted correctly. Assuming approval equals payment causes downstream write-offs that could have been prevented with claim-level validation.

---

### Denial response (peer-to-peer review vs. formal appeal)

**Goal:** Determine whether the denial is reversible and select the appropriate escalation path.

Decision criteria on receiving a denial:
- What is the denial reason? (Administrative denial — missing information, untimely submission, wrong format — vs. medical necessity denial vs. non-covered service denial. These have different response paths.)
- Is the service actually covered? (Non-coverage denials are not the same as medical necessity denials; appealing a non-covered service on medical necessity grounds will not succeed)
- Is the denial based on missing clinical documentation (fixable by resubmission with complete documentation) or on a coverage policy determination (requires appeal on the policy)?
- What is the appeal deadline? (Typically 30–60 days from denial date for commercial plans; 30 days for Medicare Advantage; Medicaid managed care varies by state. Missing this deadline extinguishes the right permanently.)

Response paths:
- **Peer-to-peer review:** The treating physician calls the payer's medical director to discuss the clinical case directly. Available for most medical necessity denials; must be requested within a defined window (often 10–14 days from denial). Peer-to-peer review overturns denials at materially higher rates than written appeals alone — it is the first escalation path for medical necessity denials, not a last resort.
- **Formal written appeal:** Required when peer-to-peer review is unavailable, unsuccessful, or when the denial is administrative. Requires: denial notice, appeal letter, supporting clinical documentation addressing the specific denial reason, and any relevant medical literature or clinical guidelines supporting medical necessity.
- **Expedited appeal:** Available when the standard appeal timeline would cause serious harm. Requires documented clinical urgency. CMS mandates 72-hour expedited appeal turnaround for Medicare Advantage.
- **External review:** After exhausting internal appeals, enrollees have the right to external independent review under the ACA. This right is non-waivable.

What to gather before appealing:
- Full denial notice with specific denial reason and appeal deadline
- Treating provider's clinical rationale — not a copy of the prior submission, but a specific response to the stated denial reason
- Any clinical literature or guidelines supporting the requested service
- Documentation that the applicable clinical criteria are met, if the denial was a medical necessity determination

---

### Appeal rights framework

Federal and state law establish a tiered appeal structure. The structure is non-waivable — payers cannot contractually eliminate these rights.

**Internal appeal (first level):** All regulated plans must offer at least one level of internal appeal before external review. The treating provider submits a written appeal with supporting documentation addressing the specific denial reason. Decision timelines: 30 days for standard internal appeals (Medicare Advantage); 60 days is common for commercial plans. Medicaid managed care state timelines vary.

**Peer-to-peer review:** Not a formal appeal level under federal law, but a clinical discussion available for most medical necessity denials. The treating physician requests a call with the payer's medical director to discuss the case. Must be requested within the payer's specified window (typically 10–14 days from denial). Not subject to the formal appeal decision timeline; outcomes vary by payer and service type. Peer-to-peer overturns medical necessity denials at materially higher rates than written appeals — use it first for medical necessity denials.

**Expedited internal appeal:** When the standard timeline would cause serious harm. CMS mandates 72-hour turnaround for expedited Medicare Advantage appeals; state mandates vary for commercial plans.

**External Independent Review (IRO):** After exhausting internal appeals, enrollees and providers have the right to external review by an Independent Review Organization under the ACA. This right is non-waivable under federal law. The IRO's decision is binding on the payer. Available for medical necessity denials and rescissions; not available for coverage (benefit) denials. Decision timeline: 45 days standard, 72 hours expedited.

**State insurance department / CMS complaint:** Parallel path available at any stage. Not an appeal, but it creates a regulatory record and can prompt payer attention on cases where the formal appeal process is stalled.

Hard dependency: Every stage has a deadline. Missing the internal appeal deadline extinguishes the right to external review. Track denial date, internal appeal deadline, peer-to-peer request window, and external review eligibility date for every denied PA.

---

### CMS regulatory timeline (FHIR-based PA automation)

CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F, January 17, 2024) requires impacted payers — Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and ACA marketplace QHP issuers — to implement FHIR-based PA APIs by January 1, 2026. The mandate covers three Da Vinci Implementation Guides:

- **Coverage Requirements Discovery (CRD):** Real-time PA requirement lookup at the point of care, triggered from within the provider's EHR workflow (HL7 Da Vinci CRD IG v2.0)
- **Documentation Templates and Rules (DTR):** Electronic delivery of payer-specific PA request forms and clinical criteria to the provider's EHR at the time of the request, eliminating fax-based form retrieval (HL7 Da Vinci DTR IG)
- **Prior Authorization Support (PAS):** FHIR-based PA request submission and response — replaces or supplements EDI 278 for in-scope payers (HL7 Da Vinci PAS IG v2.0)

CMS-0057-F additional requirements effective January 1, 2026:
- Decision timelines: 72 hours for expedited/urgent requests; 7 calendar days for standard requests (these replace the prior 14-day standard timeline for MA plans)
- Reason for denial: payers must include a specific reason for denial in the PA response — a denial code alone is insufficient
- Annual reporting: payers must report PA approval and denial rates, decision timelines, and rates by service type to CMS annually starting 2026
- Treating provider notification: payers must notify the treating provider of PA decisions, not just the requesting provider

What CMS-0057-F does not cover: commercial employer-sponsored (ERISA) plans are not in scope; most commercial fully-insured plans will not be mandated until states act. Large self-funded employer plans are governed by ERISA and are not subject to this rule.

Agents building PA automation for in-scope payers should design to the Da Vinci FHIR IGs, not just EDI 278. The FHIR APIs are the mandated pathway for a large and growing share of covered lives from January 2026 forward. EDI 278 remains relevant for out-of-scope payers and for payers that support both channels during transition.

---

## Information requirements summary

| Stage | Information required | Common failure mode |
|---|---|---|
| Benefit verification | Eligibility response, covered benefit confirmation, PA requirement flag | Proceeding to PA without confirming coverage |
| PA requirement determination | Code-specific PA requirements from current payer source | Relying on stale PA requirement knowledge |
| Clinical documentation assembly | Applicable criteria set, documentation gap analysis | Submitting documentation that addresses general need, not specific criteria |
| Submission | All required data elements, correct submission pathway | Rejection due to missing elements; misrouted submission |
| Status tracking | Reference number, current status, pending response deadlines | Pended requests aging out without response |
| Approval | Auth number, authorized codes, quantity, date range, provider match | Missing auth number on claim; service outside authorized window |
| Denial response | Denial reason category, appeal deadline, peer-to-peer availability window | Missing appeal deadline; appealing non-covered services on medical necessity grounds |
<!--fold:7f8407@end-->
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    # Match <!--fold:<m>@file path="X"--> with an optional mode attr after
    # the path (fold emits  mode="644"  on executables).
    file_re = "^<!--fold:" m "@file path=\"([^\"]+)\"( mode=\"[0-9]+\")?-->$"
    end_re  = "^<!--fold:" m "@end-->$"
  }
  $0 ~ end_re { if (current) close(current); exit }
  $0 ~ file_re {
    if (current) close(current)
    line = $0
    sub(/^<!--fold:[^@]+@file path="/, "", line); sub(/".*$/, "", line)
    current = outdir "/" line
    dir = current; sub(/\/[^\/]*$/, "", dir)
    if (dir != current) system("mkdir -p \"" dir "\"")
    printf "" > current
    next
  }
  current { print >> current }
' "$DEST"
SEED_EXTRACTED=$(find "$TARGET" -type f -not -path "$DEST" 2>/dev/null | wc -l)
if [ "$SEED_EXTRACTED" = "0" ]; then
  echo "seed: archive contained no files — refusing to delete the source" >&2
  echo "  archive preserved at: $DEST" >&2
  exit 1
fi
rm -f "$DEST"

echo "" >&2
echo "✓ seed unpacked → $TARGET ($SEED_EXTRACTED files)" >&2
find "$TARGET" -type f | sort | while IFS= read -r _sf; do
  echo "  ${_sf#${TARGET}/}" >&2
done
echo "" >&2
if [ -f "$TARGET/SKILL.md" ]; then
  echo "This seed contains a skill (SKILL.md). Install it in your agent's skills directory." >&2
  echo "" >&2
fi
echo "Install the seed skill if not already installed:" >&2
echo "  https://seed.show/skill" >&2
echo "" >&2
echo "Publisher prompt:" >&2
sed 's/^/  /' >&2 <<'__SEED_PROMPT_END_AC1F2B__'
You have the prior authorization context. Read README.md for the PA mental model, provider/payer tension, payer criteria vs. clinical guidelines distinction, agent failure modes, and what AI is changing. Read workflow.md for the full PA lifecycle — benefit verification through denial appeal — including the appeal rights framework and the CMS-0057-F FHIR mandate. Fetch sources.md for live CMS rules and payer-specific criteria. Critical: never imply a PA will be approved; payer decisions are final subject to appeal. To share your own context bundles: curl seed.show/skill | bash
__SEED_PROMPT_END_AC1F2B__
exit 0