What does this skill do?

Skill Medical Guidelines Reviewer audits medical guidelines and procedures before they are submitted to insurance companies, identifying incomplete fields, incorrect codes, and discrepancies between diagnosis and procedure. It returns a structured report that includes an overall status, a field checklist, a clinical consistency analysis, necessary corrections, and a rejection risk classification.

Pre-shipment inspection
Review a batch of claims forms before submitting them to the insurance company or health plan to avoid claim denials.
Diagnosis of Recurrent Rejections
Identify the root causes of errors that lead to a high return rate and correct them at the source.
Guidelines for Complex Procedures
Audit specific procedures that often raise questions or result in rejections due to clinical inconsistencies.
Training for Administrative Staff
Train new staff to review documentation using a structured approach and a specific order of verification.

Usage examples

📤 Pre-shipment inspection
Review this Sanitas claim form before submitting it: beneficiary María López, diagnosis H90.3, procedure: pure-tone audiometry, code 40301374, provider Juan Pérez, license number 12345.
🔍 Common Mistakes
I have a 30% rejection rate for referral guidelines with the Adeslas insurance company. Please review these 5 guidelines and tell me what recurring error pattern you see.
🩺 Clinical consistency
Review this procedural guideline: diagnosis M54.5, epidural injection procedure, orthopedic surgeon. Does the diagnosis justify the procedure?
🎓 Staff Training
Please explain the step-by-step process for reviewing a medical guideline so that my new administrative team can learn it.

Features

Validation of Required Fields Check the status of each required field: correct, incomplete, or missing, with a description of the problem.
Clinical Consistency Analysis Verify whether the ICD-10 diagnosis justifies the procedure and whether the procedure is consistent with the professional's specialty.
Rejection Risk Classification Assign a risk level (Low, Medium, High, Critical) along with a justification to prioritize fixes.
Actionable corrections For each problem detected, specify the field, the error, how to fix it, and the urgency.
Supporting Documentation Note Indicate whether any supporting documents or additional medical requests are required before submission.

Frequently asked questions

Reference guides for procedures, exams, hospitalizations, and dental care. Simply specify the type of guide at the beginning of your search.
No. The skill works with the data you enter in the prompt. It does not require access to external insurance systems.
Yes. Enter the operator's name in the corresponding field, and the skill will apply the general audit criteria for medical guidelines.
Yes. The skill includes a structured review process (field integrity → codes → diagnosis vs. procedure → documentation → authorization) that is ideal for training.
Medical Guidelines Reviewer — Billing Audit with Claude AI

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