Question 1

What evidence do you review in a healthcare-payer engagement?

Accepted Answer

We review the representative claims or status records, prior-authorization records, X12 837/835/278 or referral inputs, active manuals and clinical criteria, code sets, adjudication logic, reviewer decisions, supporting evidence, and relevant access, change, and audit records that the payer supplies. The review is scoped to that supplied evidence: it supports workflow and review documentation, but it is not coverage, payment, medical-necessity, certification, or delegated payer judgment.

Question 2

How are healthcare-payer engagements scoped?

Accepted Answer

We define one workflow, its evidence sources, the decision boundary, the stakeholders and reviewers, and the handoff artifacts up front. That keeps the work bounded and fixed in scope around a specific payer workflow rather than implying a broad transformation. The output is review support and traceability for the agreed boundary, not a transfer of coverage, payment, medical-necessity, certification, or payer decision-making responsibility.

Question 3

What does the Eligibility Rules Sprint produce?

Accepted Answer

The sprint produces a bounded evidence inventory, a map separating rules-based work from human research, a representative sample review, traceability and gap findings, and a prioritized next-step brief. It is an evidence-anchored way to decide what can be organized or automated next; it is not a coverage determination, medical-necessity determination, certification, payment decision, or delegated payer judgment.

Question 4

Where does human research remain required?

Accepted Answer

Qualified payer, clinical, and compliance reviewers remain responsible for ambiguous policy language, clinical nuance, exceptions, incomplete or changing source material, and final interpretation and approval. Automation can surface, organize, and trace the evidence for review, but it does not replace human judgment or become the payer, clinical, coverage, payment, medical-necessity, certification, or compliance decision-maker.