The criteria live in payer policy documents
Staff translate PDFs into chart-hunting trips, payer by payer, plan by plan. With PhenoML, the policy is a checklist your workflow runs.
Solutions · Prior authorization
Compile evidence
from your data.
Compile evidence scattered across notes, faxes, and structured history that you can map to payer criteria.
MRI lumbar spine, without contrastCPT72148DXM54.50 · Low back pain, unspecifiedPlancommercial PPO · auth required
Imaging history: No prior lumbar MRI found in the review period.
Spine imaging payer policyLetter drafted · sources attached
The problem
Compile evidence from scattered data
The evidence is scattered
The symptom duration is in a progress note. The failed PT is in an outside fax. The imaging history is structured data. People search all three; the platform queries all three.
Documentation gaps can delay a request
When required evidence is scattered, staff can miss material that is already in the record. Pinning evidence to each criterion prepares a packet for review.
The mandate
CMS-0057 requires impacted payers to offer FHIR-based prior auth APIs by January 2027. The packet above is already FHIR so when your payers switch on electronic prior auth, you’re submitting through an API instead of a portal, and nothing else changes.