rubric.md

Prior Authorization Decision Rubric

This file defines the decision rules for generating recommendations (APPROVE/PENDING/DENY).

Before making any decision, always read this file first to understand the current policy.

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Default Policy: Lenient Mode

Goal: Request additional information instead of denying. Only approve when clearly supported.

Decision Rules

What to Check	If Problem Found	Action	Why
Provider NPI not verified	Yes	PENDING	Request provider credentialing documentation
CPT/HCPCS codes invalid	Yes	PENDING	Request code clarification or corrected submission
ICD-10 codes invalid	Yes	PENDING	Request diagnosis code clarification
Coverage policy not found	Yes	PENDING or continue	May need manual policy research
Required criteria NOT_MET	Yes	PENDING	Request additional clinical documentation
Required criteria INSUFFICIENT	Yes	PENDING	Request specific missing documentation
All required criteria MET	Yes	APPROVE	Clinical evidence supports medical necessity
Unclear/uncertain	Yes	PENDING	Default safe choice when can't determine

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How to Apply These Rules

Follow this order:

1. Check provider verification

   • If provider not verified → PENDING (request credentialing docs)

2. Check code validation

   • If any CPT/HCPCS codes invalid → PENDING (request corrected codes)
   • If any ICD-10 codes invalid → PENDING (request corrected codes)

3. Evaluate medical necessity criteria

   • If all required criteria MET → APPROVE
   • If any required criteria NOT_MET or INSUFFICIENT → PENDING (request more clinical documentation)
   • If unclear → PENDING (safe default)

That's it! Simple lenient approach.

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Customizing This Rubric

To Enable DENY (Strict Mode)

If your organization wants to automatically deny certain requests instead of pending:

Change the Action column in the table above:

• Provider NPI not verified → Change PENDING to DENY
• Invalid codes → Change PENDING to DENY
• Required criteria NOT_MET → Change PENDING to DENY

Then update Step 3 in "How to Apply These Rules":

If provider not verified → DENY
If any codes invalid → DENY
If required criteria NOT_MET → DENY (only use PENDING for INSUFFICIENT)

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Override Rules

Users can override recommendations in Subskill 2:

• PENDING → APPROVE: Allowed (if sufficient docs received)
• PENDING → DENY: Allowed (with clinical justification)
• APPROVE → DENY: Allowed (requires justification)
• APPROVE → PENDING: Allowed (requires justification)