Prior Authorization Intelligence Agent Prototype

Claude LLM API + Airtable + Zapier Webhooks. Implementation in 4 hours over 2 days.

I gave myself a 2-day deadline to create a no-code configurable prior authorization agent. Final stats:

Total Time Investment: 4 hours

Coding required: None

Total Cost: $0-$50 (subscription cost varies)

Business Value: Addresses $30B annual healthcare problem

AGENT’s JOB: Predict prior authorization approval likelihood for MRI

Input: Insurance plan + MRI procedure + patient info

Output: Approval probability + required documents + timeline

DESIGN

1. Base LLM: Claude API (Model: claude-3-5-sonnet-20241022)

2. Insurance Plans table in Airtable. Airtable API to read Insurance Plans table.

BUILD CORE WORKFLOW

1. Create Input Form using Google Forms with the following fields:

   1. Insurance Plan (use the dropdown from Airtable)

   2. MRI Type (Brain, Spine, Knee, etc.)

   3. Patient Age

   4. Diagnosis

   5. Previous treatments tried

2. (Setup Zapier Automation

   1. Trigger: New Google Form submission

   2. Action 1: Airtable “Find Record” (get insurance plan rules)

   3. Action 2: Format data for Claude

   4. Action 3: HTTP POST to Claude API

   5. Action 4: Send result via email

3. Create Claude Prompt Template

   You are a Prior Authorization Specialist.

   INSURANCE RULES:

   {{Airtable.Imaging_Rules}}

   {{Airtable.Processing_Time}}

   {{Airtable.Approval_Rate}}

   {{Airtable.Required_Documents}}

   MRI REQUEST:

   - Type: {{Form.MRI_Type}}

   - Patient Age: {{Form.Age}}

   - Diagnosis: {{Form.Diagnosis}}

   - Previous Treatment: {{Form.Treatments}}

   Provide ONLY the following:

   1. Approval Likelihood: High/Medium/Low (with %)

   2. Required Documents: Bullet list

   3. Timeline: X business days

   4. One tip to improve approval chances

   Keep response under 200 words

WRAP IN SIMPLE INTERFACE

• Start with Google form (built above)

  E.g. Insurance Plan: Blue Cross Blue Shield MA PPO MRI Type: MRI Lumbar Spine Patient Age: 45 Diagnosis: Chronic lower back pain Previous Treatments: Physical therapy for 4 weeks Email: your-email@domain.com

• Users with the link to Google Forms can get results via email (not shown above)

  E.g. APPROVAL LIKELIHOOD: Medium (70%) REQUIRED DOCUMENTS:• Clinical notes showing 6+ weeks conservative treatment• Physical therapy records and outcomes• Pain scale documentation PROCESSING TIMELINE: 3-5 business days OPTIMIZATION TIPS:• Document functional limitations in daily activities• Include PT discharge summary showing minimal improvement POTENTIAL ISSUES:• Insufficient conservative treatment duration (need 6+ weeks)

TEST & ITERATE

Test cases to run:

1. BCBS MA + MRI Brain + migraine diagnosis

2. UnitedHealth + MRI Spine + back pain

3. Medicaid + MRI Knee + sports injury

Iteration Cycle:

1. Submit test case → Check result quality

2. Adjust Claude prompt → Test again

3. Refine Airtable data → Test again

CONFIGURATION TIPS

1. Setup Zapier trigger

   App: Search “Google Forms”

   Event: Select “New Response in Spreadsheet”

   Account: Connect your Google account

   Spreadsheet: Select your Prior Auth form responses spreadsheet

   Worksheet: Usually “Form Responses 1”

2. Build the JSON Payload (Data section)

   {

   “model”: “claude-3-5-sonnet-20241022”,

   “max_tokens”: 1000,

   “messages”: [

   {

   “role”: “user”,

   “content”: “You are a Prior Authorization Intelligence Assistant.\n\nINSURANCE PLAN RULES:\n- Plan: [Map: Airtable Plan_Name]\n- Processing Time: [Map: Airtable Processing_Time]\n- Approval Rate: [Map: Airtable Approval_Rate]\n- Imaging Rules: [Map: Airtable Imaging_Rules]\n- Required Documents: [Map: Airtable Required_Documents]\n- Common Denials: [Map: Airtable Common_Denial_Reasons]\n\nPRIOR AUTH REQUEST:\n- MRI Type: [Map: Google Forms MRI Type]\n- Patient Age: [Map: Google Forms Patient Age]\n- Diagnosis: [Map: Google Forms Diagnosis]\n- Previous Treatments: [Map: Google Forms Previous Treatments]\n\nProvide a structured analysis with:\n1. APPROVAL LIKELIHOOD: High/Medium/Low with percentage\n2. REQUIRED DOCUMENTS: Specific checklist\n3. PROCESSING TIMELINE: Expected days\n4. OPTIMIZATION TIPS: How to improve approval chances\n5. POTENTIAL ISSUES: Common denial reasons for this case\n\nKeep response professional and actionable for healthcare staff.\n\nDISCLAIMER: For informational purposes only. Verify current payer policies.”

   }

   ]

   }