Medical policy metadata is the backbone of intelligent prior authorization automation. It's what enables the system to instantly route an auth request to the correct policy. For UM workflows, metadata allows teams to filter and search policies by specialty, body area, or auth category rather than hunting through hundreds of documents. Metadata also powers member and provider transparency portals allowing queries of coverage criteria by CPT code and other fields.
Without robust metadata, you're just digitizing PDFs; with it, you're building an intelligent engine that scales to multiple uses cases.
Metadata is configurable with Policy Studio, so we can support different organizational structures and workflows, but it’s important to define the core elements consistently. The goal is to capture the minimum required fields to ensure accurate policy lifecycle management, interoperability, and governance. This list is not comprehensive but represents a recommended baseline.
Core metadata fields include (representative examples, not exhaustive):
Clinical Identifiers:
- CPT codes
- HCPCS codes
- ICD-10 diagnosis codes
Operational Attributes:
- Title
- Subtitle
- Policy number
- Public version number
- Policy type
- Policy source
- Policy source URL
- Level of care
- Auth category
- Specialty
- Body area
- Population type
- Applicable states
- Effective date
- Last review date
- Next review date
Your specific metadata schema will be configured based on organizational taxonomy, regulatory requirements, and operational workflows.