Healthcare · Deterministic · Certified · Auditable

Deterministic Policy Enforcement for Regulated Healthcare.

Compile healthcare policy into certified decision packages. Execute deterministically with full provenance, audit trails, and governed builds. AI assists at compile time — runtime decisions are reproducible and traceable.

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Zero AI at runtime. Deterministic. Auditable. Traceable.

The problem in healthcare

Manual prior auth delays care

Prior authorization requests take days of manual review. Inconsistent criteria application leads to denials, appeals, and delayed treatment. Rules should be deterministic and auditable — not dependent on who reviews the case.

Formulary rules are trapped in PDFs

Drug coverage policies, step-therapy requirements, and exception criteria exist in documents that no system can execute consistently. Sertainly compiles them into certified, versioned decision packages with full source-document provenance.

Billing compliance is reactive

Coding errors and compliance violations are caught after submission — not prevented at the point of service. Decision infrastructure enforces rules before claims leave your system.

How Sertainly Helps

Prior Authorization

Medical necessity criteria, required documentation, and coverage rules compiled into deterministic decision packages linked to source policy clauses.

  • Coverage determination against payer-specific auth criteria
  • Medical necessity checks with required clinical evidence
  • needs_info returned when imaging or lab results are missing
  • Full trace with policy citations for appeals and peer review

Formulary Enforcement

Drug coverage rules — formulary tiers, step-therapy sequences, quantity limits, and exception criteria — versioned and executed deterministically.

  • Step-therapy sequence enforcement (e.g. try generic before brand)
  • Quantity limits and days-supply caps per formulary tier
  • Exception criteria evaluation with clinical evidence requirements
  • Version-pinned formulary logic with source-document provenance

Billing Compliance

CPT/HCPCS code validation, modifier rules, and documentation checks executed before claim submission — not caught on denial.

  • Pre-submission CPT and HCPCS code validation
  • Modifier compliance (e.g. -25, -59 usage rules)
  • Documentation sufficiency checks against payer requirements
  • Signed decision trace for audit and payer disputes

Clinical Pathway Eligibility

Patient eligibility for care programs, treatment protocols, and referral pathways evaluated with deterministic, policy-driven rules.

  • Protocol eligibility screening (e.g. oncology pathway enrollment)
  • Risk stratification rules for care management tiers
  • Referral requirements and specialist authorization criteria
  • Identical decisions across providers, sites, and systems

Prior Authorization: coverage determination

An agent submits a prior authorization request. Sertainly evaluates coverage criteria and returns a deterministic verdict with full trace.

evaluate_case input

{
  "package_id": "prior_auth_policy",
  "version": "4.1.0",
  "case": {
    "patient": {
      "age": 67,
      "diagnosis_code": "M17.11",
      "insurance_plan": "MEDICARE_ADVANTAGE"
    },
    "procedure": {
      "code": "27447",
      "description": "Total knee replacement",
      "setting": "INPATIENT"
    },
    "clinical_evidence": [
      "FAILED_CONSERVATIVE_TREATMENT",
      "IMAGING_CONFIRMS_SEVERITY"
    ]
  }
}

evaluate_case output

{
  "verdict": "compliant",
  "reason_codes": [
    "MEDICAL_NECESSITY_MET",
    "CONSERVATIVE_TREATMENT_DOCUMENTED",
    "IMAGING_REQUIREMENT_SATISFIED"
  ],
  "trace_id": "tr_pa_4f8a…"
}

Ready to get started?

Enterprise plans include dedicated runtime, governance workflows, certified builds, VPC deployment, and full audit controls.

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Ready for deterministic, auditable healthcare decisions?

Compile policy into certified decision packages. Execute deterministically with full trace, provenance, and audit controls. Same decision layer across every use case.

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