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.