For Patient Access Representatives ·
What you'll accomplish
Paste a payer policy document into Claude and ask your question in plain English, and you get a clear answer in 2-3 minutes instead of 20-30 minutes on hold with a payer hotline. This guide shows you how to use Claude's document reading capability for payer policy questions and PA requirement lookups.
What you'll need
Go to claude.ai in a web browser.
What you should see: A chat interface with a text input box at the bottom and Claude's greeting at the top.
Click "New Chat" in the left sidebar. This gives you a fresh context window for your payer question.
Give Claude context before asking your question, which dramatically improves accuracy:
What you should see: Claude confirms it's ready to help with coverage policy analysis.
Find the relevant section of the payer's coverage policy (from their provider portal, usually under "Coverage Policies" or "Clinical Policy Bulletins").
Copy the relevant text and paste it into Claude with your specific question. Example:
"Does the following policy require prior authorization for a lumbar spine MRI (CPT 72148) in an outpatient setting for a patient with a Medicare Advantage plan? Please give me a yes/no answer and cite the specific language that determines this. [paste policy text]"
What you should see: Claude provides a direct answer with the specific clause that determines PA requirements, not a hedge or a "it depends."
You can ask follow-up questions in the same conversation without re-pasting the policy:
Copy Claude's summary and paste it into a notes document, a shared OneNote page, or an email to your supervisor. This builds a searchable record of payer policy interpretations your team can reference later.
Troubleshooting: If Claude gives an uncertain answer, it usually means the policy text itself is ambiguous. In that case, Claude will tell you what specific question to ask the payer's provider line.
Determine PA requirement:
I'm a patient access rep. Does the following payer policy require prior authorization for [procedure name, CPT code] in an [outpatient/inpatient] setting for a [plan type] patient? Give a yes/no answer with the specific policy language. [paste policy]
Understand denial reason:
A prior authorization was denied for [procedure] with the denial reason: "[exact denial language]". Based on typical payer policies, what does this denial reason mean, and what are the most common ways to successfully appeal it?
Patient explanation:
A patient's prior authorization was denied. Explain in plain English (no jargon) what "[denial reason]" means and what options the patient has.
Identify required documentation:
For a prior authorization for [procedure] with [payer], what clinical documentation is typically required? List the most common requirements.