For ASC Coordinators ·
What you'll accomplish
Lengthy insurance clinical policy documents distilled to plain English in under 5 minutes, so you know exactly what criteria to document before submitting a prior authorization request. Claude does the reading; this guide shows you how to ask it the right questions.
What you'll need
What you should see: The Claude interface: a clean conversation window with a text input at the bottom.
Most major insurance companies publish their clinical coverage policies online. Here's how to find them:
Anthem/BlueCross: anthem.com → providers → clinical resources → medical policies Aetna: aetna.com → health care professionals → clinical policy bulletins Cigna: cigna.com → health care providers → coverage policies UnitedHealthcare: unitedhealthcareonline.com → policies → coverage policies Humana: humana.com → providers → prior authorizations → clinical guidelines
Search the policy page for the procedure name or CPT code. Download the PDF. These documents are often 15-40 pages long.
What you should see: A PDF with the insurance company's specific criteria for covering this procedure.
Open the PDF. Use Ctrl+A (Windows) or Cmd+A (Mac) to select all text, then Ctrl+C to copy. If the PDF is very long, copy just the "Coverage Criteria" or "Medical Necessity Criteria" sections. Those are the critical pages.
Go to your Claude conversation. Type:
"I'm going to paste an insurance company's clinical coverage policy. After I paste it, I'll ask you specific questions about what's required for prior authorization approval. Here is the policy:"
Press Enter, then paste the policy text. Wait for Claude to acknowledge it.
What you should see: Claude confirms it has received the document and is ready for your questions.
Now ask exactly what you need to know:
"Based on this policy, answer these questions: 1. What are the specific medical necessity criteria that must be met for this procedure to be covered? 2. What documentation must I include in the prior authorization request? 3. What diagnoses or conditions are excluded from coverage? 4. What prior treatments must be documented as having failed? 5. Is there a step therapy requirement (must try other treatments first)? 6. What is the appeals process if the request is denied?"
What you should see: A structured, plain-English summary answering each of your questions directly.
Copy Claude's response into a Google Doc or your notes. Title it "[Insurance Company] - [Procedure Name] - Coverage Requirements" and save it to your shared template folder.
Next time you submit a case for the same procedure with the same payer, you have a ready reference and no need to re-read the 40-page policy.
Troubleshooting: If Claude says the document is too long, paste just the "Indications and Limitations" section rather than the entire policy, since that section contains the criteria you need.
For any new procedure + payer combination:
Based on this policy, what are the exact criteria I must document to get [procedure] approved with this insurance company? Give me a checklist format.
When you've had repeated denials:
We've had three denials for [procedure] from this payer recently. Based on this policy, what are we likely missing in our authorization requests?
For understanding appeal rights:
Based on this policy, what is the appeal process for denied authorizations? What are the time limits? What should I include in an appeal?
For comparing two policies:
Here is [Payer A]'s policy. [Paste it.] Now here is [Payer B]'s policy. [Paste it.] Compare them: where do the criteria differ? Which one is more restrictive?