Applied workflows for healthcare operations.

By January 1, 2027, impacted payers must run a prior authorization API, return decisions within 72 hours (urgent) / 7 days (standard) with a specific denial reason, and publicly report PA metrics. CMS-0062-P (proposed) extends this to drugs and broadens the same workflow.

PA criteria sit in prose documents and internal systems. Providers must call, fax, or use vendor portals. Clinical context is lost in translation. When criteria change, providers don't know; denials increase. No audit trail linking a denial to documented criteria.

Express coverage criteria as auditable components for discovery, documentation, and submission. Surface requirements inside the EHR before submission. Reduce call volume, reduce staff time, accelerate decisions. The audit trail survives appeal.

Accurate coding and coverage decisions are core to revenue cycle and compliance. But coding rules are complex and fragmented. Coders lack real-time guidance. Coverage decisions drift from documented policy. Appeal success depends on audit trails that don't exist.

Coding guidance lives in manuals, LMS courses, and tribal knowledge. Coverage policies are prose. When codes change, training lags. Coders second-guess themselves. Denials spike. Appeals require reconstructing decision logic months after the fact.

Encode coding and coverage rules as deterministic, auditable components. Integrate directly into RCM workflows. Coders see decision logic in real time. Every coding decision produces an audit trail linking to source policy. Appeals become straightforward: show the criteria that were applied.