Claude Project: Build a Prior Authorization Documentation System

What This Builds

A persistent Claude Project configured with your most common prior authorization request types, payer-specific language preferences, and medical necessity criteria — so instead of spending 30–60 minutes drafting a prior auth packet from scratch, you input clinical bullet points and get a complete, persuasive narrative in 5 minutes. For nurses who routinely help case managers with complex discharge planning, this can reclaim hours of frustrating administrative work each week.

Prerequisites

• Claude Pro subscription ($20/month at claude.ai)
• Familiar with using Claude for clinical writing (Level 3)
• Understanding of your unit's common prior auth request types (ask your case manager)
• 1.5 hours for initial build and knowledge base setup

The Concept

A Claude Project gives you a persistent workspace where Claude retains uploaded documents and a custom system prompt across all conversations. For prior authorization work, you can upload:

• Common payer clinical criteria documents (de-identified)
• Prior auth templates your case management team uses
• Medical necessity criteria for your most common requests
• Your unit's common diagnosis clinical profiles

Think of it as a well-trained documentation specialist who already has the payer's criteria memorized, knows what clinical language reviewers respond to, and can assemble a professional narrative from your raw clinical facts in minutes.

Build It Step by Step

Part 1: Gather your materials

Before building, collect these items (all de-identified, no patient info):

From your case management team:

• What are the 5 most common prior auth requests from your unit? (Home health, SNF, home oxygen, DME, home IV antibiotics are the usual suspects)
• Do you have the payer criteria for any of these? (Medicare home health criteria, LCD for home oxygen, etc.) — ask your case manager or check your hospital's CM resource drive
• Any denial templates or approval templates you can learn from?

From your own experience:

• What information do reviewers always ask for that nurses forget to include?
• Which requests get denied most often and why?

Part 2: Create the Claude Project

1. Log into claude.ai with your Pro account
2. Click "Projects" in the left sidebar → "New Project"
3. Name it: "Prior Auth Documentation System"
4. Click "Project Instructions" and add your system prompt:

You are a prior authorization documentation specialist for a registered nurse working in hospital acute care. Your job is to help draft clinical necessity narratives for prior authorization requests for post-discharge services.

MY UNIT CONTEXT:
Unit type: [Medical-surgical / PCU / Cardiac / Orthopedic / etc.]
Common discharge destinations requiring prior auth: home health nursing, home PT/OT, SNF placement, home oxygen, hospital beds, wound care supplies, home IV antibiotics

PRIOR AUTH NARRATIVE PRINCIPLES:
1. Open with diagnosis and clinical status (quantified where possible)
2. Describe functional limitations in measurable, concrete terms
3. Articulate why skilled care is required — specifically why unskilled care, family teaching, or patient self-management is insufficient
4. Include qualifying clinical criteria (O2 sat levels, transfer status, wound complexity, medication complexity)
5. State the specific service requested with frequency and duration
6. Close with expected outcome if authorized vs. risk if denied

LANGUAGE STYLE:
- Professional clinical language
- Active voice
- Specific and measurable (avoid vague terms like "limited mobility" — use "ambulates 50 feet with maximum assistance of 2")
- Use standard payer-recognized terminology

FORMATTING:
- Narratives should be 200–400 words (concise but complete)
- Use paragraph format (not bullet points) for most payers
- Lead with most compelling clinical information
- Always end with risk statement if authorization is denied

CRITICAL: Never include real patient names, MRNs, or identifying information. Nurses describe patients in de-identified clinical terms.

Part 3: Upload reference documents

In your Project, click the paperclip/attachment icon to upload documents. Good candidates:

Medicare Home Health Coverage Criteria — available publicly from CMS (cms.gov). Search "Medicare benefit policy manual home health." Download the relevant chapter as a PDF and upload.

Your payer-specific criteria — if your case manager has PDF summaries of Blue Cross, Aetna, UHC, or Medicaid criteria for common requests, ask for the de-identified versions.

Medical necessity criteria examples — your hospital's case management team may have approved authorization templates they're willing to share.

Once uploaded, Claude can reference these criteria directly when drafting narratives: "Based on the Medicare homebound criteria in your documents, this patient qualifies because..."

Part 4: Build your template library

Spend 30 minutes creating master templates for your 5 most common prior auth types. For each one, ask Claude to create a reusable template:

"Create a reusable prior authorization narrative template for home health skilled nursing visits. Use [BRACKETS] for the parts I'll fill in per patient. Include all standard medical necessity elements. Make it 250–350 words."

Do this for:

• Home health skilled nursing
• Home health PT/OT
• Home oxygen (O2 criteria)
• SNF placement
• DME (hospital bed / power wheelchair)

Save each template as a named reference in your Project's uploaded files or in a separate note.

Part 5: Build your rapid-entry workflow

Once your Project is set up, your workflow becomes:

1. Get case from case manager — they tell you: "We need a home health auth for [patient type], [payer], [requested services]"
2. Collect your clinical facts (de-identified bullet points, 5 minutes at the bedside)
3. Open your Prior Auth Project → paste clinical facts + request
4. Claude generates the narrative (30–60 seconds)
5. Review, edit, paste into your payer's portal or give to case manager to fax

Total time: 10–15 minutes vs. 30–60 minutes from scratch.

Real Example: SNF Placement Authorization

Setup: Case manager asks you to help draft a medical necessity narrative for SNF placement for a patient who failed home health criteria. Insurance is requesting justification.

Your de-identified clinical facts:

• Post-stroke, 8 days hospital
• Right-sided weakness, functional movement 2/5
• Aphasia — can follow simple commands but cannot express needs independently
• Requires max assistance for all ADLs
• Complex medication regimen (anticoagulation, blood pressure medications, seizure prophylaxis)
• Lives alone, no caregiver available
• Cannot participate in outpatient therapy due to medical complexity and transportation limitations

What you type in your Prior Auth Project: "Write a prior auth narrative for SNF placement for a post-stroke patient. Clinical facts: [paste your bullet points above]. Insurance is requesting justification. Emphasize skilled nursing needs and why home with home health is not appropriate."

What Claude generates: A 300-word professional narrative opening with clinical severity, detailing the skilled care requirements (complex medication management, aphasia requiring skilled communication strategies, daily nursing assessment for post-stroke complications), explaining why home placement is not clinically appropriate (lives alone, no caregiver, cannot safely manage independently), and stating the specific SNF criteria being met.

Time saved: 35–45 minutes per complex case

What to Do When It Breaks

"The narrative doesn't match what this payer usually wants" → Upload the payer's specific criteria to your Project. Ask Claude: "Draft this narrative using the [payer] criteria I uploaded."

"The case manager says it's missing required elements" → Ask your case manager to tell you the specific elements payers are requiring. Add these to your Project instructions under "Required elements for [payer]."

"We're getting denials even with the AI narratives" → Review your denial letters. They will cite specific unmet criteria. Bring this back to Claude: "This request was denied for [reason]. How do I address this in the narrative given these clinical facts?"

"Claude doesn't know the current Medicare homebound criteria" → Upload the current CMS criteria document to your Project. Claude will reference the uploaded document rather than potentially outdated training data.

Variations

Simpler version: Skip the full Project setup. Use a saved prompt template in Claude's free tier for your most common request type. Paste, fill in the brackets, done. Less powerful but still saves 20–30 minutes per case.

Extended version: Build a second Project specifically for denial appeals. Upload successful appeal narratives as reference documents. Use it to draft peer-to-peer review talking points for your physicians when cases are denied.

What to Do Next

• This week: Build the Project setup and create templates for your top 3 prior auth request types
• This month: Track time saved per case for 4 weeks — you'll have a compelling data point to share with your nurse manager
• Advanced: Share the approach with your case management team. A coordinated system where case managers and nurses both contribute clinical detail to the same Project becomes significantly more powerful than individual use.

Advanced guide for registered nurse professionals. Claude Pro required for Projects. Prior authorization criteria change frequently — always verify current payer criteria with your case management team.