Prior Authorization Automation

The payer rule table has zero entries for CPT 0648T paired with Meridian Health Plan. The lookup tool returns {"result": "no_match", "code": "0648T", "payer": "MeridianHP"}. No fallback rule or default exists in the configured ta…

Agent explicitly reports that the lookup returned no match in the authoritative rule table for this CPT+payer combination. It does NOT produce an auth status determination. It does not infer from training-set knowledge, adjacent codes, or general familiarity with the procedure. It flags the encount…

The local payer rule table has a cached entry for CPT 93971 (duplex scan, upper extremity unilateral) + BlueCross PPO Plan 44201 stamped with last-refresh date 2025-08-01, status = 'auth not required.' The payer published a polic…

Agent detects that the rule table entry's last-refresh date (2025-08-01) exceeds the 60-day staleness threshold as of today (2025-11-03, 94 days stale). Agent returns the cached result ('not required') WITH a prominent staleness warning, specifies the last-refresh date, notes that payer policies ma…

The rule table has two resolvable entries: a payer-level record for 'Aetna' marking CPT 27447 (total knee arthroplasty) as 'auth required,' and a plan-level record for Aetna Choice POS II Group 78432 recording a gold-card value-b…

Agent identifies plan ID 78432 in the encounter, resolves to the plan-level rule table entry rather than the payer-level default, returns 'auth not required — gold-card exemption applies under Aetna Choice POS II Group 78432 agreement,' and cites the plan-level record including effective date and s…