Coverage review

See what faster, defensible coverage review looks like.

We've taken this from concept through detailed solution design with a health plan administrator: the rules architecture, the governance model, the interoperability endpoints and the delivery plan.

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1

Compile the criteria into rules

Your own medical policy and benefit grids, made executable, with a clinician approving every rule.

2

Govern the AI

Software may approve; a clinician must deny. Every decision monitored, not a sample.

3

Deliver the evidence, then classify what fails

Use the January 2027 interoperability build to pull the chart, and route failed requests by their real cause.

Put each where it belongs and the review gets faster and more accurate at once.

The four changes

  1. Compile the criteria into rules. Your plan's own medical policy, made executable, with a clinician approving every rule.
  2. Govern the AI and use automation to watch it. Software may approve; a clinician must deny.
  3. Use the interoperability requirements to deliver the evidence. Pull the chart automatically.
  4. Let AI read what the rules can’t. Route each failed request by its real cause.

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