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.
Industry context
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.
Corules provides the deterministic policy enforcement layer that Healthcare organizations need to deploy AI agents in production — with audit trails that satisfy regulators and governance teams.
Regulatory requirements
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.
Corules's immutable audit ledger records every decision with: policy set version, actor identity (from signed claims — never from LLM output), normalized input hash, outcome, and reason. This creates a complete compliance trail for any regulatory examination.
Key decision types
These are the structured decisions most commonly enforced with Corules in Healthcare:
- 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
Applicable use cases
These Corules use cases are commonly deployed in Healthcare organizations:
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.
Deploy Corules in your Healthcare environment
Talk to our team about industry-specific policy templates and compliance configurations.
Talk to us