Prior Authorization Evidence Router

Payer Rules

The rule map is where evidence requirements turn into actual reimbursement work.

This lane maps payer requirements to evidence targets, owner lanes, readiness, and blockers that still prevent safe approval routing.

Payer Rule	Target Evidence	Owner	Readiness
Conservative treatment proof Blue Harbor Health Surgical approval	Six-week therapy timeline with failed response notation	Utilization Review	yellow
Peer review rationale packet SummitCare PPO Imaging reimbursement	Ordering rationale plus prior treatment and symptom-duration proof	Revenue Cycle	red
Signed behavioral plan validation Union State Health Plan Program enrollment	Treatment plan signature and current progress-note verification	Clinical Intake	yellow
Infusion start attestation North River Advantage Specialty medication start	Physician attestation plus monitoring plan reference	Pharmacy Ops	green

Dependency Blockers

RULE-21 · Utilization Review

Therapy timeline exists in notes, but it is not extracted into the payer packet yet.

clinical · Surgical approval

RULE-27 · Revenue Cycle

Ordering rationale is still trapped in free-text notes and not mapped into the outbound review form.

utilization · Imaging reimbursement

RULE-33 · Clinical Intake

Signature coverage is inconsistent across imported plan documents.

clinical · Program enrollment

RULE-39 · Pharmacy Ops

No blocker; only packaging and outbound routing remain.

appeal · Specialty medication start