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Healthcare proof asset · synthetic
A policy change is not real until every downstream system behaves differently.
This assessment makes one prior-authorization modernization scenario inspectable across member eligibility, benefit coverage, procedure policy, provider qualification, UM routing, and the claims control that survives after clinical review is removed.
The wedge
The commitment is simple. The execution environment is not.
Removing prior-authorization review for a defined population sounds like one rule change. In practice, the answer is assembled from multiple authorities and must still produce behavior that legacy clinical and claims platforms can consume.
Benefit coverage, authorization policy, provider qualification, clinical review, and claims evidence are different decisions. Collapsing them into one flag is how burden-reduction programs create payment defects, manual workarounds, and conflicting provider experiences.
The first job of modernization is to make those decisions explicit: who owns each one, which inputs control it, when it is effective, what happens when facts conflict, and what record the next system needs.
AI can assist the workflow. It cannot substitute for an undefined authority model.
This is a synthetic, educational prototype. It does not use PHI, determine benefits, reproduce a payer's policy, submit prior authorization, or make a clinical decision. Its purpose is to expose the operating and architecture questions a real implementation must answer.
System boundaries
Six authorities. One reconstructable decision.
The orchestration layer does not become the master of every fact. It resolves effective-dated inputs from the systems that already own them, applies governed logic, and records the resulting path.
- 01
Member & eligibility
Which coverage is active for the service date, and which plan and line of business govern?
- 02
Benefit coverage
Is the requested service covered? This is not the same question as whether authorization is required.
- 03
Procedure policy
For this plan, service, place, state, and effective date, what administrative requirement applies?
- 04
Provider program
Does an active qualification apply to the submitted provider TIN and the requested service?
- 05
UM orchestration
Should the request bypass review, enter plan UM, or route to a delegated specialty workflow?
- 06
Claims control
Which durable record must downstream adjudication find so the claim follows the intended path?
Assessment model
From executive commitment to observable outcome.
A real assessment follows the change across six dimensions before recommending a platform, integration, automation, or AI intervention.
01
Commitment
The burden-reduction, access, regulatory, or platform outcome leadership has committed to deliver.
02
Population
Affected plans, lines of business, accounts, provider entities, services, states, and effective dates.
03
Authority
The system or team that owns each fact, rule, qualification, exception, and approval.
04
Execution
The applications, integrations, operational teams, delegated partners, releases, and migration paths involved.
05
Control
The evidence, exception route, appeal, requalification, audit trail, and claims artifact that keep the change safe.
06
Outcome
The baseline and observations required to prove activation, administrative-burden change, and unintended fallout.
Impact, not activity
The prototype exposes a decision. The sprint defines the evidence a release needs.
No administrative-burden or outcome claim is implied by the lab. Those claims require a baseline, activation evidence, and observed post-change behavior.
| Proof layer | Question | Required evidence |
|---|---|---|
| Activation | Eligible scenarios reaching the intended route | Decision traces by plan, provider, service, and effective date |
| Administrative burden | Touches, active minutes, calls, rework, and elapsed time | A pre-change baseline and segmented post-change observations |
| Claims continuity | Missing or mismatched control artifacts and related fallout | Notification/auth creation matched to downstream claim behavior |
| Exceptions | Unresolved inputs, manual routes, appeals, and requalification | Root-cause categories with an accountable owner |
Standards and evidence boundary
The model is informed by public healthcare interoperability patterns, including the CMS Interoperability and Prior Authorization Final Rule and the HL7 Da Vinci Coverage Requirements Discovery, Documentation Templates and Rules, and Prior Authorization Support implementation guides. Those standards define important exchange behavior; this prototype's policy, qualification, orchestration, and claims-control model is TKO advisory work, not a claim of conformance.
One principal · Priced up front
Which healthcare commitment is getting lost between policy and production?
Bring one bounded change. TKO will map the authorities, decisions, systems, controls, failure paths, and evidence required to make it executable.