The Context Layer. Where your institutional knowledge becomes enforceable policy.
The Context Layer encodes your medical policies, clinical guidelines, and plan rules into a single governed library. Versioned, traceable, and applied consistently across every Ai workflow on the Operating System.
Your policies live in PDFs, spreadsheets, and people's heads. The Context Layer gives them a governed home.
Clinical criteria, plan rules, coding policies. Encoded once in a single versioned library. Applied consistently across every Ai workflow. Auditable forever.
Before (scattered)
After (governed)
- Clinical criteria — PDF v2024Medical necessity criteria
- Evidence guidelines — PDF, lockedClinical guidelines
- Plan rules — Confluence pagePlan rules
- Billing rules — Spreadsheet (outdated?)Billing and coding policies
- Coding policy — email thread from Q3Care pathway definitions
Capabilities
01
Provenance
Every rule traceable to its source, author sign-off, and full history. Auditors get the complete trail.
02
Version Control
Full policy history. Replay any determination against the exact version of the policy active at time of service.
03
Explainability
Every Ai Worker recommendation surfaces the exact rules and reasoning path used. Clinical staff can defend any recommendation.
04
Role-Based Governance
Author, approve, deploy. Segregation of duties built in. Compliance is structural, not manual.
Every rule tied to its source, sign-off, and history. Nothing is assumed. Everything is shown.
When the regulator asks how a determination was made, the answer is one click away. Source. Author. Reviewer. Approver. Active date. All attached to the version that ran.
Source
Evidence-based clinical criteria, §4.2
Encoded by
VP Clinical Affairs
Reviewed by
Clinical Governance Committee — Mar 14
Approved by
Chief Medical Officer — Mar 21
Active since
April 1, 2024 · v2.4.1
Every determination replayable. Against the exact policy that was active at the time.
Three years from now, when a determination from today gets audited, you can rerun it against the exact policy version that governed it. No reconstruction. No guesswork.
Version history
- v2.4.1Apr 1, 2024Updated lumbar criteria — Q1 refreshActive
- v2.4.0Jan 15, 2024Added behavioral health addendum
- v2.3.2Oct 3, 2023Hotfix — cardiac stent coverage update
- v2.3.1Jul 18, 2023Annual review — imaging criteria
- v2.3.0Mar 1, 2023Major release — post-acute guidelines added
Replay any determination against any prior version →
Every determination surfaces the exact rules and evidence path behind it. No black box. No guessing.
When clinical staff need to defend a recommendation, they get the reasoning trace, not just the outcome.
Prior Auth #PA-002291 · Lumbar MRI
Approved- Policy appliedMedical necessity criteria v2.4.1 §4.2
- Criterion metConservative therapy ≥6 weeks documented
- Evidence citedClinical notes 2024-03-01, 2024-03-22
- Criterion metNeurological symptom — radiculopathy confirmed
- Rule invokedPlan Rule §7.1 — imaging pre-auth threshold
- Approved byAi Worker · governed by Context Layer v2.4.1
Author. Approve. Deploy. Compliance built into the structure, not bolted on after.
Encode once. Apply everywhere, consistently.
Utilization Management
Draws from: Medical necessity criteria · Length-of-stay guidelines
Revenue Cycle
Draws from: Contracted rates · Billing rules · Code mappings
Patient 360
Draws from: Care pathway definitions · Risk stratification rules
HCC Coding & Risk Adjustment
Draws from: Coding policies · Diagnosis mapping rules · RAF methodology
All drawing from the same Context Layer library