Claude Project: Advanced Prior Authorization System with Insurer Templates

What This Builds

An advanced prior authorization system where Claude has your insurer-specific templates, your clinic's common diagnoses, CPT code combinations, and denial patterns all pre-loaded. Instead of explaining context every time, you open your dedicated project and Claude already knows everything about how your clinic handles prior auths. Letters are more precise, approval rates improve, and the entire workflow takes under 10 minutes per auth.

You'll also build a tracking system in Google Sheets that feeds into your auth workflow, so you always know which auths are pending, which were approved, and which denials need appeals.

Prerequisites

• Claude Pro account ($20/mo) — Projects require Claude Pro for persistent document storage
• Google account (free) for the tracking spreadsheet
• Your clinic's list of most common insurers and auth requirements
• 2–3 hours for initial setup
• Approved prior auth letters you've written (to use as style examples for Claude)

The Concept

This is like having a medical billing specialist on call who already knows your clinic, your patients, and every insurer's quirks — and is available at midnight when you're catching up on auths.

The "specialization" happens through Claude Projects: you upload documents, templates, and guidelines that Claude reads as background knowledge. Every conversation in that project starts from that knowledge base.

Build It Step by Step

Part 1: Collect Your Prior Auth Intelligence

Before touching any tech, gather:

From your existing records:

• 3–5 prior auth letters that were approved for each common diagnosis (these are your style examples)
• 2–3 denial letters from each major insurer (these reveal what language didn't work)
• Any insurer-specific prior auth forms you've saved

From your clinic experience:

• List of your top 10 diagnoses requiring prior auth
• Typical CPT code combinations for each diagnosis
• Common denial reasons you see from each insurer
• Approximate visit counts you request for each diagnosis

This is the intelligence layer that makes the system dramatically better than generic Claude.

Part 2: Create Your Claude Project

1. Go to claude.ai → Log in → Click "Projects" in the left sidebar
2. Click "New Project" → Name it: "Prior Authorization System — [Clinic Name]"
3. Click "Add Content" to upload your clinic-specific knowledge:

   • Upload your successful prior auth letter examples (as text or Word files)
   • Create a text file called "Insurer Notes" with your observations about each payer
   • Create a text file called "Diagnosis Protocols" with your typical treatment protocols per diagnosis

Sample "Insurer Notes" document to upload:

INSURER-SPECIFIC PRIOR AUTH GUIDANCE

Medicare/Medicare Advantage (Humana, Aetna MA, UHC MA):
- Key phrase: "Skilled physical therapy services are required because..."
- Emphasize: functional deficits requiring professional clinical expertise
- Avoid: any language suggesting "maintenance" or "stabilization only"
- Request cycles: typically 8 visits at a time
- Common denial: "No continued skilled need" — counter with objective functional progress data

Aetna (commercial plans):
- Responds to: evidence-based treatment rationale, clinical practice guidelines
- Include: expected functional outcomes with specific timelines
- Request: up to 12 visits; they rarely approve more than 12 at once
- Denial pattern: often denies "passive modalities" — frame everything as therapeutic

BCBS (varies by state — these notes apply to [your state]):
- Very responsive to: specific ROM and strength measurements
- Return-to-work framing significantly improves approval for working-age patients
- Include: patient's occupation and specific job demands
- Typical approval: 10–12 visits for orthopedic conditions

UnitedHealthcare:
- Most evidence-based payer — cite clinical practice guidelines when possible
- APTA CPG references carry weight
- Request: 8 visits for acute, 12 for post-surgical
- Be very specific about treatment duration and frequency (they audit for compliance)

1. Write your Project Instructions:

You are a prior authorization specialist for an outpatient physical therapy clinic. You have access to our clinic's approved prior auth letters, insurer notes, and treatment protocols in this project.

Your role:
- Draft prior authorization letters tailored to each specific insurer's requirements
- Draw on the successful letter examples in this project for appropriate language and structure
- Use the insurer-specific notes to tailor language to each payer's known criteria
- Always include: diagnosis, functional limitations (specific and ADL-related), objective measurements, CPT codes and rationale, visit count request, and functional outcome goals

Format: professional medical letter format, no patient names (use "patient" with demographic info), ready to print on clinic letterhead

Quality check: before finalizing, confirm the letter (1) clearly establishes medical necessity, (2) quantifies functional limitations, (3) projects specific functional outcomes, and (4) requests a specific and justified visit count.

Part 3: Build the Google Sheets Tracking System

Create a Google Sheet called "Prior Auth Tracker":

Color coding:

• Green: Approved
• Yellow: Pending (submitted, awaiting decision)
• Red: Denied
• Blue: Appeal in progress

Spend 2 minutes per auth updating this sheet. Patterns will emerge: which insurers have the highest denial rates, which diagnoses get denied most, how long each payer takes to respond.

Part 4: Establish Your Weekly Auth Workflow

Monday morning (30 minutes): Review the tracker. Move any pending auths to follow-up if they've been waiting more than 10 business days. For denials, open Claude project and generate appeal letters.

End of clinic day (as needed): For new patients requiring auth, open Claude project and generate the letter in under 10 minutes. Update tracker.

Friday afternoon (15 minutes): Review tracker for anything needing action. Identify patterns in the week's denials.

Real Example: Complete Prior Auth from New Referral to Submission

Setup: New referral arrives for a 55-year-old with cervical radiculopathy with arm pain. She has Aetna commercial insurance. Your evaluation shows cervical ROM limited to 30° flexion, 3/5 right hand grip strength, Spurling's positive, and she reports she cannot type for more than 10 minutes without hand numbness — significantly affecting her job as a paralegal.

Step 1: Add to Google Sheets tracker → "JD" | Aetna Commercial | Cervical Radiculopathy | 3/20/26 | 12 visits | Pending | —

Step 2: Open your Prior Auth System Claude project (already has your Aetna notes and letter examples)

Input:

Prior auth for Aetna commercial. Cervical radiculopathy with C6-7 involvement. Patient: 55yo female paralegal. Functional limitation: cannot type >10 min without right hand numbness, sleep disrupted by arm pain, cannot turn head safely to check blind spot while driving. ROM: cervical flex 30°, right rotation 25° (severely limited). Strength: right grip 3/5 (left 5/5). Spurling's positive right side. Requesting 12 visits over 6 weeks for manual therapy (97140), therapeutic exercise (97110), and cervical traction (97012). Goal: restore cervical mobility, reduce radicular symptoms, return to full-duty work as paralegal.

Output: A complete Aetna-specific prior auth letter referencing evidence-based treatment rationale, using Aetna's preferred functional outcomes framing, with all required elements — in under 60 seconds.

Step 3: Review letter, add clinic letterhead details, submit via Availity

Total time: 8 minutes from patient chart to submitted auth.

What to Do When It Breaks

• Claude doesn't use the uploaded documents → Check that files were successfully uploaded (they appear in the "Files" section of your project). Re-upload if missing.

• Letters don't match the insurer's style → Your insurer notes document needs more specific guidance. After a denial, add the denial reason and what language change worked in the appeal to your insurer notes document.

• Approval rates don't improve → Run a diagnostic: compare denied letters to approved letters for the same diagnosis. Identify the specific language difference and add that pattern to your Claude project instructions.

• Project instructions getting too long → Create separate short documents for each insurer and upload them as files instead of putting everything in the instructions field.

Variations

• Simpler version: Skip the Google Sheets tracker and just use Claude Projects without the tracking system. You still get the insurer-specific letter quality improvement.

• Extended version: Add a Zapier automation that logs auth submissions from your email to the Google Sheet automatically (Zapier → Gmail → Google Sheets). Reduces the manual tracking step.

What to Do Next

• This week: Complete Part 1 (collecting your auth intelligence) — this is the hardest step
• This month: Build the system, run 10 auths through it, compare approval rates to your baseline
• Advanced: Add a quarterly review to update your insurer notes with new patterns — the system improves continuously as you add data

Advanced guide for physical therapist professionals. Prior authorization requirements change frequently — verify current insurer criteria. De-identify all patient information when working with AI tools. Consult your compliance officer regarding HIPAA requirements for your specific tool setup.