Processes
Enforce medical policy
How enforce medical policy are reshaped as AGI capability advances.
ProcessesEnforce medical policy
Business-as-Code
Read as an executable program — the work decomposed into Code, Generative, Agentic, and Human.
Enforce medical policy sits inside a larger value-flow — 1 parent structure it composes into. The hierarchy is grounding, not the story: it tells you which aggregate exposure Enforce medical policy inherits.
Where Enforce medical policy sits
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How the work flows
Trigger: A medical claim or prior authorization request is submitted by a healthcare provider for review.
- Ingest prior authorization request or flagged medical claim
- Retrieve corresponding member benefit plan and clinical policies
- Evaluate submitted clinical documentation against medical necessity criteria
- Route complex or ambiguous cases to a medical director
- Formulate the final coverage determination
- Generate and transmit the decision notice to the provider and member
Outcome: The service is formally approved, denied, or adjusted in alignment with documented medical necessity criteria and plan benefits.
Measured by
Decision Turnaround TimePolicy Adherence RateFirst-Level Appeal Overturn Rate