سياسات التغطية
Structured Payer Prior-Authorization Policies & Deterministic Coverage Rules
✓ القواعد صريحة، ومُحددة الإصدار، وقابلة للتدقيق.Demo Policy Library (v1.0.0)
Select Payer Policy (7)
POL-RHEUM-BIO-Av1.0.0 Effective: 2026-08-01
Demo policy — Rheumatology biologic therapy
Fictional demo policy — not an insurer contract.
Target Requested Service Codes
BIO-DEMO-001
Structured Evaluation Criteria (6)
Confirmed inflammatory diagnosis§1.1
Weight: 4%Mandatory
Diagnosis must be documented.
Expression: {"op":"equals","factKey":"diagnosis_confirmed","value":true}
Remediation Action: Document the confirmed diagnosis if clinically established.
Active disease/severity documented§1.2
Weight: 4%Mandatory
Disease activity or severity must be documented.
Expression: {"op":"equals","factKey":"disease_activity_documented","value":true}
Remediation Action: Document current disease activity/severity if assessed.
Conventional therapy failure/intolerance§2.1
Weight: 80%Mandatory
Prior conventional therapy failure or intolerance must be explicitly documented.
Expression: {"op":"equals","factKey":"conventional_therapy_failure_documented","value":true}
Remediation Action: Document prior conventional therapy, duration, and response/intolerance if true.
Baseline safety screening§3.1
Weight: 3%Mandatory
Required baseline safety screening must be documented.
Expression: {"op":"equals","factKey":"tb_screening_complete","value":true}
Remediation Action: Attach/document required baseline safety screening if available.
Contraindication screening§3.2
Weight: 3%Mandatory
Relevant contraindication screening is documented.
Expression: {"op":"equals","factKey":"contraindication_screen_complete","value":true}
Remediation Action: Document contraindication screening if performed.
Clinical rationale§4.1
Weight: 6%Mandatory
Reason for treatment escalation is documented.
Expression: {"op":"equals","factKey":"clinical_rationale_present","value":true}
Remediation Action: Document a concise clinical rationale if true.
Required Clinical Attachments
Recent specialty clinic noteRequired
Baseline safety screeningRequired