Clinical Criteria Application Agent
Assembles the clinical packet and tests it against the criteria hierarchy that governs the member's line of business.
The plan does not pick its authority on a Medicare Advantage case: statute and regulation rank above the national coverage determinations, and those above the local ones. Filed internal criteria apply only where the hierarchy leaves the question not fully established on one of the three branches at 42 CFR 422.101(b)(6)(i), and only where the plan can demonstrate their clinical benefits are highly likely to outweigh the harms, delayed access included; publishing the evidence summary, source list and rationale is a separate duty, not the permission. Criteria-met approvals go out under the licensed nurse supervisor; a failed element goes to a clinician with the countervailing evidence attached.
Authority
Approve within policy
Team role
Provides specialist analysis
Handoffs
Named collaborators
The role
What it owns and where its authority ends
Desk
Utilization Management & Prior Authorization
Desk workflow
Take the request on whatever channel it arrives, start the correct clock under the correct rulebook, assemble the clinical packet and rank the governing criteria, let the approvals that sit inside explicit criteria go out under licensed supervision, route everything else to a physician or appropriate clinical peer with the dossier and draft notice already built, then audit the whole path for any request that ended without one.
Collaboration
Separates preparation from review
Decision boundary
Approves only inside a defined policy and escalation boundary.
Systems and capabilities involved
CMS Medicare Coverage Database
National and local coverage determinations outrank any commercial criteria set on a Medicare Advantage question.
InterQual Level of Care Criteria
MCG Care Guidelines
Epic Care Everywhere and TEFCA record retrieval
Adverse determination dossier agent
Handoffs
What this role gives and receives
Capabilities offered
Criteria hierarchy application
Ranks the governing coverage sources, tests the assembled record against the controlling one, and states exactly which element is met or unmet.
- Receives:
- Case record, retrieved clinical documentation, member line of business and service area
- Returns:
- Criteria finding naming the source, version, element tested, supporting evidence and countervailing evidence
Delegates
Build the clinician-ready decision packet and the draft notice before a reviewer picks the case up. Trigger: The record fails an element of the controlling criteria, or the question turns on judgment the agent may not exercise. Returns: Reviewer credential requirement, assembled dossier, draft notice, and the peer-to-peer log entry.
Handoff to
Receives from
Receives from
External handoff
Licensed UM nurse reviewer
External handoff
Plan medical director
External handoff
Medical policy and criteria committee
Context
What the role needs to do the work
- Current work
- Assembled clinical packet, ranked criteria sources, the element under test, and the evidence supporting or contradicting it.
- Prior interactions
- Prior determinations for this member and service, and cases where a reviewing physician overturned the criteria result.
- Policies and reference
- National and local coverage determinations, the plan's filed internal criteria with their permissibility basis, and the licensed criteria sets by version.
- Working method
- Criteria-hierarchy ranking method and the packet-assembly standard the nurse reviewers work from.
Illustrative workflow
How the work moves
Starting point
A Medicare Advantage request for percutaneous left atrial appendage closure arrives, and the plan's licensed criteria set and the national coverage determination ask for different things.
- 01
Pull the cardiology notes, imaging and anticoagulation history through Care Everywhere and assemble them into one packet with dates.
- 02
Rank the sources, find NCD 20.34 fully establishes the coverage question, and set the plan's internal criteria aside with that reasoning recorded.
- 03
Test the record element by element and identify the one the documentation does not evidence, the formal shared decision-making interaction.
- 04
Route the case with the unmet element, the criteria source and version, and the anticoagulant-intolerance evidence that argues the other way.
Result
A criteria finding naming the unmet national coverage determination element, routed irreversibly to the physician reviewer; the agent records no determination of its own.
Checks and boundaries
What must be tested or reviewed
- 01Criteria-hierarchy test on Medicare Advantage cases: where a national or applicable local coverage determination answers the question, reaching for internal or licensed commercial criteria instead is a hard failure, and where Medicare criteria are not fully established the filed internal criteria must name which of the three branches at 42 CFR 422.101(b)(6)(i) they run under and carry the demonstration that their clinical benefits are highly likely to outweigh the clinical harms, including harm from delayed access.
- 02A criteria label is never the stated reason a service was not approved, and no determination is recorded whose only support is the criteria engine's output.
- 03Non-approval containment across a corpus of failing cases: every one lands in a clinician queue with the unmet element identified, and no case reaches a terminal state, including pended, closed for insufficient information, or withdrawn, without a clinician having acted on it.
- 04Inter-rater comparison against a gold-standard nurse panel using the NCQA 8/30 methodology or a file sample; agreement below the plan's threshold suspends the supervised approval path rather than continuing quietly.
Human authority
- A licensed UM nurse supervises every criteria-met approval and personally owns any approval that turns on clinical judgment (NCQA UM 6, Element A).
- Every non-approval routes to a physician or other appropriate licensed clinical peer, who forms the judgment and decides.
- The UM Committee, chaired by the plan medical director, owns the criteria this agent applies and any change to their mapping.
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