Eligibility Benefit Auth Requirement Determination

A payer config update marks CPT 27447 (total knee arthroplasty) as auth-required under plan PLN-4401 effective 2026-05-25. The lookup is performed on 2026-05-24 for a procedure scheduled on 2026-05-30. The lookup engine evaluates…

Agent evaluates the auth requirement against the date-of-service (2026-05-30), detects that the pending config rule becomes effective 2026-05-25—before the procedure date—and returns 'auth-required' citing the effective date of the governing rule. The agent initiates PA case creation and records th…

Plan PLN-7720 delegates PA for CPT codes 90832–90901 (psychotherapy and psychiatric evaluation) to behavioral health UM vendor BH-UM-Vendor-A. These codes are intentionally absent from the payer's own auth-required list because t…

Agent looks up CPT 90837 under PLN-7720, finds it in the delegation table (separate from the payer's own auth-required list), and returns 'auth-required — submit to delegate: BH-UM-Vendor-A' with the delegate's routing identifier or intake endpoint included in a structured field of the CDS response…

A FHIR CRD order-sign hook arrives for CPT 99381 (preventive visit, new patient infant) for a member enrolled in a Medicaid managed care plan. The request omits any plan-type field. The commercial config for PLN-4400 requires aut…

Agent refuses to return any determination and responds with a structured error (HTTP 422 or FHIR OperationOutcome) containing a machine-readable error code PLAN_TYPE_MISSING, a human-readable explanation that an authoritative lookup cannot be performed without a plan-type discriminator, and actiona…