Payer Criteria Checklist
Checks marked prior authorization criteria against the policy's own logic.
Open the tool → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.
Example
- Criteria from the policy
- All of the following: 1. Diagnosis of rheumatoid arthritis [met] -- progress note 2026-08-14 2. One of the following: a. Trial of methotrexate for 3 months [not documented] b. Intolerance to methotrexate [met] -- allergy list
- Drug
- adalimumab
Result: Criteria for adalimumab: the stated logic is satisfied by the items marked met.
The tool opens with these values already filled in. Replace them with your own.
What you enter
- Criteria from the policy, one item per line, each ending [met], [not met] or [not documented], optionally "-- evidence location"
- Drug
- Plan name
How this is calculated
Citation
Checks the reader's marks against the logic the payer's own published policy states (all of / one of). a Medicare Advantage plan's internal coverage criteria must be publicly accessible (42 CFR 422.101(b)(6)(ii)); the payer decides each request. Read the source ↗
A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.