AI Policy Enforcement for Healthcare Operations and Prior Authorization
Health plans and providers use Corules to gate prior authorization decisions, referral approvals, and care management recommendations. AI assessments are validated against medical necessity criteria before decisions render. Every PA decision is auditable for CMS and NCQA review.
Le problème
Health plans and providers use Corules to gate prior authorization decisions, referral approvals, and care management recommendations. AI assessments are validated against medical necessity criteria before decisions render. Every PA decision is auditable for CMS and NCQA review.
Contexte réglementaire
CMS interoperability rules require payers to respond to PA requests within 72 hours (urgent) or 7 days (standard). The No Surprises Act governs cost estimate delivery. NCQA accreditation requires documented UM criteria. Proposed CMS rules (2026) require AI-driven PA decisions to include specific denial reasons.
Types de décisions clés
- Prior authorization approval and medical necessity determination
- Referral approval and specialist routing
- Step therapy and formulary exception review
- Care management program eligibility
- Out-of-network cost estimate delivery
Cas d'usage associés
Frequently Asked Questions
How does Corules satisfy CMS PA response time requirements?
Corules evaluates PA requests synchronously. Policy-compliant requests return ALLOW immediately, meeting urgency requirements. Ambiguous cases escalate to medical directors with full clinical context preserved.
Can payer medical necessity criteria be encoded in CEL?
Yes. Clinical criteria (diagnosis codes, procedure codes, required documentation) are expressed as CEL constraints referencing parameter tables. Criteria updates via parameters do not require policy redeployment.