Medical Policy MP-114PDF · 42 pp
Payer policy infrastructure
Every payer rule,
structured.
Coverage, prior-auth and medical-necessity rules—normalized, versioned and ready for your product.
For RCM, EHR, billing and healthcare software teams.
Payer rules · before / after
sandbox example
Fragmented today
Prior-auth list — portalHTML · quarterly
UM vendor bulletinFAX / PDF
Structured with PayerGraph
codes/check · answer
200
coveragewith_conditions
prior_authrequired
criteriaavailable
versionv6 · eff 07-01
sourceMP-114 · p.12
confidencehigh
Payer policy is fragmented by default.
PayerGraph turns scattered documents and shifting criteria into one queryable source of truth.
Fragmented sources
Policies live across portals, PDFs and delegated vendors.
Constant change
Rules shift quietly. We preserve versions and effective dates.
Clinical prose
Dense criteria become structured logic your software can use.
The intelligence layer
One API. Every payer requirement.
Policy intelligence
Search by payer, plan, geography, code or clinical concept.
POST /v1/policies/searchPrior authorization
Know whether a code is required, conditional or unknown.
POST /v1/codes/checkMedical necessity
Query clinical criteria without losing the original logic.
GET /v1/medical-necessity/:idVersioned evidence
Trace every answer to its date, version and source.
GET /v1/policies/:id/versionsAPI first
Built into your workflow.
Send payer context and codes. Get normalized JSON with source citations.
Connect
Authenticate once through the API.
Query
Send payer context and medical codes.
Build
Put structured answers inside your workflow.
Use cases
Policy intelligence for the workflow you already own.
Your product owns the workflow. PayerGraph supplies the answer.
Pre-service checks
Answer coverage before scheduling.
Claim scrubbing
Catch policy conflicts before submission.
Prior-auth discovery
Know which codes require authorization.
Documentation guidance
Surface the criteria a note must satisfy.
Appeal preparation
Cite the rule active on the date of service.
Change monitoring
Turn policy changes into workflow events.
Payer comparison
Compare one code across payers and plans.
Coverage research
Map how procedures are covered across markets.
Change intelligence
Know when the rules change.
Receive structured change events before yesterday’s answer becomes today’s error.
policy.change.detectedsandbox exampleCPT 70553 added to prior-authorization list
- Previous value
not_required- Current value
required- Effective date
2026-10-01- Affected product
- Example Health Plan · Commercial PPO
- Source
- Prior Authorization List — Oct 2026 (PDF)
- Webhook delivery
delivered · 200
Traceable by design
Answers that can be inspected, not just accepted.
Source citations
Every answer links back.
Effective dates
Know when each rule applies.
Version history
Query any date of service.
Confidence
Uncertainty stays visible.
Conflict detection
Contradictions are surfaced.
Human review
Low-confidence results are flagged.
Audit-ready records
Versions and retrieval dates included.
Build with PayerGraph
Make payer policy programmable.
One structured layer for coverage, medical necessity and prior authorization.