Develop medical policy rules

Trigger: A change in clinical guidelines, emergence of new medical technology, or regulatory update necessitates a new or revised coverage policy.

1. Identify the need for a new or updated medical policy
2. Review clinical literature, medical evidence, and regulatory guidelines
3. Draft clinical coverage criteria and care limitations
4. Approve the draft policy via a clinical committee or medical director
5. Translate the approved policy into computable business rules
6. Test the rules against historical claims to validate accuracy and financial impact
7. Deploy the codified rules to claims processing and prior authorization systems

Outcome: Formalized medical policy rules are approved, codified, and deployed into the claims and utilization management systems.