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Payer Medical Policy Criteria Summary
Every coverage criterion pulled out as a row, with the documentation it needs, the policy version it came from, and where your payers disagree.
River's payer policy criteria summary reads a plan's medical policy and turns it into rows. Each coverage criterion becomes one line naming the documentation element that satisfies it, the policy identifier and version it was read from, and whether an exclusion applies. Send one policy and you get a submission checklist. Send the policies of every plan you bill for the same service and you get the register, plus the diff that shows where they disagree.
Unlike the summaries that rank for this search, the useful output is not one policy explained. It is the comparison. A practice's standard authorization packet contains the criteria every plan asks for, because those are the ones staff learned by repetition. The submissions that come back are the ones missing a criterion only one plan names, and that criterion is invisible until you set the policies side by side and count how many of them mention each requirement.
This is for authorization staff working a queue, practice managers who want the requirement written down rather than remembered, and billing companies handling several plans for one specialty. Build the register once per service, then reuse it across patients. The clinician still supplies and signs the clinical content: this organizes the payer's requirements, it does not judge care. Once the criteria are on paper, a medical necessity letter is written against them one by one, in the plan's own order.
Where the criteria actually live
Start with whether the plan is allowed to have its own criterion at all. A Medicare Advantage plan may only write internal coverage criteria where Medicare's own rules leave a gap. Where it does, the regulation requires the plan to publish the criteria in use, the evidence and the rationale in a publicly accessible way. So the first question is not what the plan's policy says. It is whether a national or local coverage determination already settles the point.
Those determinations are in the Medicare Coverage Database, and two details about it decide whether a search finds anything. A local coverage determination belongs to one contractor and one geography, so the answer differs by state and there is no single national version to quote. The code list generally is not in the determination itself: CMS states that procedure codes appear in the Billing and Coding Article beside it, which is a separate document with its own identifier.
Halstead Spine and Pain Institute pulled four plans' policies for one imaging service. The 39 criterion rows collapsed to 14 distinct requirements, six of which every plan named. Three were named by exactly one plan each. One wanted the referring physician's identifier on the form rather than in the attached chart, one wanted prior therapy listed as dates, and one pended anything without its own policy number on the request. Of 128 submissions that quarter, 23 came back, and 19 were missing one of those three.
How it works
Send the policy
The plan's medical policy document, however you got it, as a PDF, a link or pasted text.
Name the service
The procedure or item you are seeking authorization for, and the plans you bill for it.
Get the register
One row per criterion with its documentation element, the version it came from, and the exclusions.
Submit against it
Work the checklist, then write the letter that answers each criterion in the plan's order.
What you get
- Every coverage criterion as its own row, with the documentation element that satisfies it
- The policy identifier, version and effective date each criterion was read from
- A submission checklist in the plan's own order, so nothing is assembled from memory
- The exclusions, and the criteria a national or local determination already settles
- A diff across every plan you bill, showing which requirement only one of them names
- The register grows per service, so the second patient costs nothing to prepare
Common questions
What if the plan will not publish its criteria?
There is a lever for that. For an employer plan under federal benefits rules, an adverse determination notice must either hand over the internal rule relied on or state that no such rule exists. Asking in writing, citing that requirement, produces the criterion or produces an admission there was none.
Does it tell me whether my patient meets the criteria?
No, and that boundary is deliberate. It restates what the plan requires and names the documentation element each requirement is satisfied by. Whether the record contains that element for a given patient, and whether the care is appropriate, are the clinician's calls. The register makes those calls faster to answer, not automatic.
How do I keep the register from going stale?
Record the policy identifier, revision and effective date on every row, which is the whole reason those columns exist. Plans revise on their own cycles, and Medicare Advantage plans must have their utilization management policies reviewed at least annually by a committee. When a policy reissues, the register tells you which pending submissions were built against the old one.
Can it handle a policy that is fifty pages long?
Yes, and length is usually where the useful criteria hide. A long policy buries its operative requirements in definitions, exclusions and a coding section that sits in a separate document. The output is the same either way: one row per requirement, the exclusions listed separately, and a note wherever the policy is genuinely silent rather than restrictive.
How many plans do I need before the comparison is worth doing?
Two is enough to be useful and four is where it gets interesting. With two you learn which requirement is not universal. With four you can rank requirements by how many plans name them, which is what separates the packet your staff should always assemble from the per-plan exceptions they keep forgetting. The prior authorization pack is where the register lives once it exists.
What happens when the denial has already arrived?
Then the criterion the reviewer applied is the one to find, and it is usually named in the notice. Pull it, add it to the register, and check whether the other plans you bill state the same thing. Where an appeal is next, the denial appeal pack writes it against the criterion rather than around it.
Does the register help with concurrent review?
That is where it earns the most, because a concurrent reviewer checks the same criteria every day. Once the register names each requirement and the documentation element behind it, each day's utilization review summary has a frame to write the change against. Without it every submission is a guess at what is being checked.
Payer Medical Policy Criteria Summary
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