Prior authorisation, eligibility, claim adjudication and appeals are administrative processes with clinical consequences. The useful line is exact: an assistant may assemble, check and prepare; a clinician decides medical necessity; and what reaches a model is bounded by the tenant’s exposure policy rather than by anyone’s good intentions.
Assigning the Healthcare Payer Operations pack brings 27 terminology overrides and 3 measured definitions with it, along with the governance defaults that decide which actions wait for a person. Everything below is what that configuration contains, not an illustration of what it could contain.The useful question is never “can it do this” — it is “what does it do without asking, and what does it bring to a person”. Each card answers both.
governedThe assistant: Assembles the administrative packet, checks the coding against the plan’s published criteria, and lists what is missing for the request to be complete.
The person: A clinical reviewer confirms medical necessity before anything is submitted. The model produces no diagnosis and no clinical recommendation.
governedThe assistant: Checks eligibility on the date of service, applies plan rules, and separates the claims that are decidable from those that are not — with the reason.
The person: Only the ones the assistant could not decide, which is the point: the queue that reaches a person is the queue that needed one.
governedThe assistant: Restates the original decision, the clauses it rested on, and what the appeal adds, in the plan’s own language.
The person: The reviewer who signs it. A denial letter is a regulated communication, not a draft an assistant may send.
Every label resolves company override → industry default → canonical, and a region filters rather than ranks — so a label added for one market cannot change what another one reads. The same resolved words assemble the agent’s prompt.
overlayPre-Authorisation (Cashless) in IN
overlayPatient in US, GB, EU and AE · Insured Member in IN
overlayThe same label in every region this pack covers.
overlayPlan Catalogue in IN
overlayThe same label in every region this pack covers.
Each measure carries a definition, the formula it is computed by and the source that defines it. That is what makes the figure defensible in a review — and what stops a model producing a plausible one instead.
kpi mapWhether an admission counts as a readmission under the Hospital Readmissions Reduction Program — unplanned, all-cause, within the window measured in whole days from discharge.
days_since_discharge = readmission_date − discharge_date, in whole days
kpi mapValidation of a ten-digit NPI, where the check digit is computed over the nine-digit base with the issuer constant prefixed — the difference between a typo caught at intake and a claim rejected weeks later.
Luhn over 80840 + first nine digits; compare against the tenth
kpi mapWeight normalised for height with the WHO adult classification applied to the rounded value, so two systems do not disagree at a band boundary.
bmi = weight_kg / (height_m)², rounded to one decimal before banding
Every deployment in this industry fails the same few ways. These are the ones the platform is built to make impossible rather than discouraged.
enforcedMedical necessity, diagnosis and treatment decisions belong to licensed people. The platform’s contribution is that the administrative work around them arrives complete and attributable.
enforcedThe exposure mode a call runs under is requested by the caller and capped by policy — masked, blind, or raw where a tenant permits it — and the event records which applied.
enforcedThe platform supplies the boundary, the records and the retention controls. It does not supply a certification, and a vendor claiming to make you compliant is selling something nobody can deliver.
Everything on this page is configuration on top of one runtime. The controls underneath it are the same for every client, and they are written out in full on the platform page.
The first scope that works is a process somebody already owns, with a decision worth keeping human. Bring that, and we will map the agents, the integrations and the approval roles around it.
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