For Utilization Review Nurses ·
What you'll accomplish
Denial letter drafting drops from 45–90 minutes to under 15 minutes per letter. This guide sets up a reusable Claude Pro workflow with a tested prompt template that produces NCQA-aligned drafts with correct appeal rights language, ready for your final clinical review and customization.
What you'll need
What you should see: Claude's main interface with a blank conversation, the input box at the bottom, and a model selector at the top.
Troubleshooting: If your organization's IT blocks claude.ai, try accessing it from a personal device on a personal account. You'll never paste actual PHI into Claude; you'll use de-identified placeholders.
Before writing your first prompt, establish your de-identification habit. Replace these elements every time:
[PATIENT][DOB][AUTH-ID][PROVIDER][DOS]The clinical content (diagnosis, objective findings, criteria reasoning) is what matters for the letter, and it can be de-identified while remaining useful.
What you should see: Nothing on screen. This is a mental habit, not a software step.
In Claude's message box, type the following (this is your base template):
You are helping a utilization review nurse draft a medical necessity denial letter. This is for a [SETTING: hospital inpatient / outpatient / skilled nursing] case.
Clinical details (de-identified):
- Diagnosis: [DIAGNOSIS]
- Service requested: [REQUESTED SERVICE OR LEVEL OF CARE]
- Criteria applied: [InterQual Acute Medical / MCG / other]
- Clinical finding: [WHY CRITERIA NOT MET - be specific]
- Length of stay reviewed: [DATES OR DAYS]
Please draft a complete denial letter that includes:
1. Denial reason stated clearly
2. Clinical criteria applied and why they were not met
3. What documentation or clinical change would support a different decision
4. Member's appeal rights with a 60-day deadline
5. Notice that a clinical peer advisor is available for peer-to-peer review
Format it as a formal letter. Do not include a letterhead; I'll add that. Use [MEMBER NAME], [AUTH NUMBER], [DENIAL DATE] as placeholders where specific data goes.
Press Enter to send. Read the output. This is your first draft.
What you should see: A full denial letter draft, typically 300–500 words, with clear sections and placeholders.
Troubleshooting: If the letter is too short or missing sections, add to your prompt: "Please expand the clinical criteria section to include more detail about what specific criteria indicators were evaluated."
Take a real case from your queue (de-identified per Step 2) and run it through the prompt. Compare the draft to your usual letter and look for:
Note what's missing and add specific instructions to your prompt template.
What you should see: A letter that's 80-90% ready. The remaining 10-20% is factual accuracy you'll verify and add.
Create separate prompt variations for your top 5 case types. For example:
Each variation adds the case-type-specific criteria language and documentation requirements.
What you should see: A small library of 5 prompt templates you can open and fill in for any case.
Claude doesn't save prompts between sessions. Save your refined templates in:
Inpatient to Observation Conversion:
Draft a denial of inpatient status / conversion to observation notice. Diagnosis: [DIAGNOSIS]. Clinical picture: [KEY FINDINGS]. Criteria: InterQual criteria not met for inpatient level; criteria for observation level are met. Include Two-Midnight Rule explanation and how it applies. Member: [MEMBER NAME], Date: [DATE].
SNF Admission Denial:
Draft a skilled nursing facility admission denial letter. Patient diagnosis: [DIAGNOSIS]. Reason for denial: [patient does not require skilled nursing services / does not meet 3-day qualifying inpatient stay requirement / other]. Include what would qualify the patient for SNF admission and appeal rights language.
Behavioral Health Continued Stay Denial:
Draft a behavioral health continued inpatient stay denial. Diagnosis: [PSYCHIATRIC DIAGNOSIS]. Current clinical status: [BRIEF STATUS]. Criteria applied: [CRITERIA]. Finding: Patient's acuity has stabilized; symptoms can be managed at a lower level of care. Include mental health parity statement and peer-to-peer availability.
Prior Auth Outpatient Procedure Denial:
Draft a prior authorization denial for an outpatient procedure. Procedure: [PROCEDURE/CPT CODE]. Diagnosis: [DIAGNOSIS]. Reason: [medical necessity not established / criteria not met / experimental]. Include what clinical documentation would support reconsideration and full appeal rights.