healthcareExamples 5Rules 5

Healthcare process automation, with a person on the step you can’t undo.

5 example healthcare processes. Each is a governed graph: agents run the reversible steps, and the irreversible ones wait for the role that must sign. Import one and adapt it — your connectors, your signers, your time limits.

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The examples
ExampleStepsGatesSignsModelled onFile
Provider-credentialing
Provider credentialing
72Credentialing committee (MSO)NCQAJSON
Clinical-trial-ops
Clinical trial operations
61Principal investigator / medical monitorGCPJSON
Pharmacovigilance
Pharmacovigilance
81QPPV / drug-safety physicianFDA/EMAJSON
Prior-authorization
Prior authorization
82Plan medical director (UM)CMSJSON
Medical-coding
Medical coding and RCM
71Revenue-cycle lead (CPC/CCS coder signs)HIPAAJSON
Why a gate
01

Provider-credentialing

Granting or denying clinical privileges is a peer-review decision with patient-safety and legal weight, so the credentialing committee or medical director signs off before a provider is approved or denied.

02

Prior-authorization

Issuing an authorization decision — especially a denial — is a regulated adverse-benefit determination with appeal rights, so a clinician signs off before a denial or a limited approval is released.

03

Medical-coding

A submitted claim is an attestation to a payer with False Claims Act exposure, so a certified coder signs off on ambiguous or high-value coding before the claim is released.

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