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
Where prior-auth work is likely to stall.
RULE-21 · Utilization Review
Therapy timeline exists in notes, but it is not extracted into the payer packet yet.
clinical · Surgical approvalRULE-27 · Revenue Cycle
Ordering rationale is still trapped in free-text notes and not mapped into the outbound review form.
utilization · Imaging reimbursementRULE-33 · Clinical Intake
Signature coverage is inconsistent across imported plan documents.
clinical · Program enrollmentRULE-39 · Pharmacy Ops
No blocker; only packaging and outbound routing remain.
appeal · Specialty medication start