For Patient Access Representatives ·
What you'll accomplish
By the end of this guide, you'll know how to use Claude (free) to quickly interpret payer policy documents, determine prior authorization requirements, and get plain-English answers to payer coverage questions — without spending 20–30 minutes on hold with payer hotlines.
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 — this 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.