Configuring Guidelines

Guidelines & EvaluationsLast updated:

This area is available to users with guideline configuration access.

Accessing Guideline Configuration

From the left navigation, select the Settings gear icon, then choose Guideline Configuration. The page opens to the Guidelines tab showing all guidelines configured for your business unit.

The Guidelines List

The guidelines list displays all guidelines your business unit has access to. You can:

  • Search by typing in the search field at the top of the table
  • Filter by type using the All / Guidelines / Exclusions / Interchange / GoldCard toggle above the list
  • Filter by business unit using the business unit filter (visible if your account spans multiple units)

Each row in the table shows the guideline name, type (Guideline, Exclusion, Interchange, or GoldCard), active status, business units, and a Last Evaluated timestamp showing when the most recent population-level evaluation completed. Click any row to open the guideline’s detail page. On the detail page, Therapeutic Interchange records show an Interchange type chip plus Source Drug and Preferred Drug in Basic Information. GoldCard records show a GoldCard type chip plus the Target Drug, and an info banner at the top explains that these configs are not run manually — a scheduled job checks your selected population against the matching rules, and members who clearly match are put through prior authorization automatically.

The detail page heading carries the title, so Basic Information covers only the drugs, indication, codes and tags. The Metadata card lists the business units the record is assigned to — by name, not by ID — along with any formularies that manage it. If the record has neither, the card says so. When available, the Metadata card also shows a Created timestamp and an Updated timestamp indicating when the record was first saved and most recently changed. These rows are omitted for older records that pre-date timestamp tracking.

The Rules section appears only when there are rules to read. Each card shows a plain-language summary of the initiation or continuation (or conversion) rules. When a rule references a reusable ontology rule, the summary names that ontology rule (for example, Patient matches ontology rule: Type 2 Diabetes) instead of showing a raw rule ID. A Therapeutic Interchange with no conversion rules shows a Conversion Rules card stating that all members on the source drug are candidates, instead of an empty rules panel. A GoldCard config shows Matching Rules — the population gate used before any prior authorization is started.

Row actions

Hovering over a guideline row reveals action icons:

  • Edit — opens the Edit Guideline panel so you can update settings (for Therapeutic Interchange rows, this opens the interchange configuration; for GoldCard rows, this opens the GoldCard configuration)
  • Clone — opens the Clone dialog to copy this guideline under a new name
  • Manage Business Units — controls which business units the guideline is assigned to
  • Delete — permanently removes the guideline (requires confirmation)

Three additional actions appear on any guideline whose title is shown in red (meaning the global template it was adopted from has been updated):

  • Preview Global Version — opens a side panel showing the current global template content so you can compare it with your copy
  • Adopt Update — overwrites your copy’s content with the latest global version; the title returns to normal color
  • Decline Update — dismisses the update notification and keeps your current version unchanged; the title returns to normal color until the global version is updated again

Update notifications

When the global team updates a guideline template that you have previously adopted, the guideline’s title turns red with an alert icon in your list. This indicates your copy is out of date. You can take action at any time using the row actions above; clicking Cancel in either dialog leaves the notification active for later review.

Adding a Configuration

Click Add in the upper right of the Guidelines tab. A panel slides in asking what you want to create:

  • Guideline — upload a clinical document and configure prior-authorization rules
  • Excluded Drugs — configure a formulary exclusion without uploading a document
  • Therapeutic Interchange — configure a source-to-preferred drug conversion for a business-unit population
  • GoldCard — configure proactive prior-authorization matching for a target drug across a business-unit population

Days Supply and Quantity Limits are not available from this menu.

Adding a Guideline

After you choose Guideline, the familiar multi-step wizard opens.

Step 1 — Upload Document

Upload a clinical document (PDF or supported file). The system parses the document to extract rule suggestions. While the file is uploading, if the transfer does not finish within about a minute you see an error asking you to check your connection and try again. After the file reaches storage, you see a Processing Document progress view while the system analyzes the content (this may take a few minutes). If the current attempt runs more than about five minutes, an orange Taking longer than expected warning appears — the page keeps watching and updates when processing finishes, so you do not need to re-upload. A true failure (for example, processing failed) still shows as a red error. When processing succeeds, the wizard advances automatically to Step 2. Because you already chose Guideline, the excluded-medication shortcut is not shown on this step.

Step 2 — Process & Select Guideline

After a document is processed, you see the parsed content alongside a list of matching guideline templates. Select the guideline that best matches the clinical criteria in the document, then click Next.

Step 3 — Configure Guideline

In the final step you set:

  • Basic details — name, indication, drug targets, tags
  • Initiation rules — the clinical criteria a patient must meet to start therapy
  • Continuation rules — the criteria required to continue an approved therapy
  • Formulary assignment — which formulary manages this guideline
  • Contact settings — how prescribers, patients, and pharmacies are contacted when this guideline generates a prior authorization task
  • Benefit type — whether the guideline applies to medical benefits, pharmacy benefits, or both
  • Letter overrides — custom letter content if your organization needs non-default messaging

Click Save to create the guideline. It appears immediately in the Guidelines list.

Adding Excluded Drugs

After you choose Excluded Drugs, the Configure step opens directly (no document upload). Set the excluded drug tokens, replacement medication, and prescriber message. Choose Benefit type — whether the exclusion applies to medical benefits, pharmacy benefits, or both — then save. The new exclusion appears in the list with an Exclusion type chip.

Adding a Therapeutic Interchange

After you choose Therapeutic Interchange, a dedicated configuration opens as a single scrolling form with three sections:

  1. Conversion — pick exactly one source drug (convert from) and exactly one preferred drug (convert to). Searching a medication offers a row for each scope: Either Brand or Generic, Generic, Any Brand, and a row for each specific brand found (for example Semaglutide (Brand: Ozempic)). Choose the row that matches the therapy you mean — picking a specific brand targets only members on that brand, so Ozempic and Wegovy stay distinct even though they share an ingredient. Each field accepts one selection, and the chip shows the scope you chose. The title and description are auto-generated from those selections in the same readable form and remain editable. Toggle whether the interchange is enabled.
  2. Population — choose Benefit type — whether the interchange applies to medical benefits, pharmacy benefits, or both — then select one or more business units whose members are in scope.
  3. Conversion Rules — build conversion eligibility rules (the same rule builder used for guidelines). Incomplete rules block save until you finish or clear them.

Until the required fields are filled, a short list above Create Interchange tells you what is still needed (source drug, preferred drug, title, business unit, or incomplete rules). Click Create Interchange to save. The new row appears in the list with an Interchange type chip. Opening the detail page also labels it Interchange and shows the source and preferred drugs. Use the list Play action later to run an evaluation — running is not part of this Add wizard.

Adding a GoldCard

After you choose GoldCard, a dedicated configuration opens as a single scrolling form. An info banner at the top explains that these configs are not run manually — a scheduled job checks your selected population against the matching rules, and members who clearly match are put through prior authorization automatically. Below that are three sections:

  1. Target — pick exactly one target drug, set the title and description (the title is auto-generated from the drug and remains editable), and toggle whether the config is enabled. Searching a medication offers the same brand/generic scope rows used elsewhere — choose the row that matches the therapy you mean. When the config is disabled, a hint under the toggle notes that disabled configs are skipped by the scheduled run.
  2. Population — choose Benefit type — whether the config applies to medical benefits, pharmacy benefits, or both — then select one or more business units whose members are in scope.
  3. Matching Rules — build the rules that decide which patients are candidates for proactive prior authorization. Matching is a gate: only an explicit match proceeds to evaluation. Patients who fail the rules, or who are missing the data needed to decide, are skipped — missing data does not trigger a data-request fax.

Until the required fields are filled, a short list above Create GoldCard tells you what is still needed (target drug, title, business unit, or incomplete rules). Click Create GoldCard to save. The new row appears in the list with a GoldCard type chip. GoldCard configs run on a schedule automatically — there is no Play / Run action on the list for them.

Editing a Guideline

Click the Edit action on any guideline row, or open the guideline’s detail page and use the edit action there.

  • For Guideline and Exclusion rows, the configuration panel opens at the Configure step with your existing settings pre-filled.
  • For Interchange rows, the Therapeutic Interchange configuration opens with the existing source/preferred drugs, benefit type, population, and rules pre-filled. Each drug chip re-opens with the brand or generic scope you originally saved.
  • For GoldCard rows, the GoldCard configuration opens with the existing target drug, benefit type, population, and matching rules pre-filled. The same scheduled-run info banner appears at the top of the panel.

Make your changes and click Save / Update.

Reviewing Evidence Checks

When you open a guideline, the Evidence Checks section shows the latest evidence review and its history. Open a check to read the reviewer summary, compare the current evidence with your guideline, and follow its source links. When the latest check is resolved, select View resolved check to open its read-only summary.

Evidence checks are available only when your account has this feature enabled. If it is unavailable, the guideline list does not show Evidence controls and the guideline detail page explains that the feature is unavailable. Any previous runs remain visible so you can review their results and resolve existing conflicts.

If a check reports a warning, tenant administrators can select Resolve after reviewing the conflicts. The same Resolve action is available in the warning banner when you edit the guideline; it takes you to the Evidence Checks review so you can inspect the conflicts before resolving them. Resolved checks show Resolved and remain in the check history. Select View resolved check to review a read-only record of the conflicts that were originally detected, including their explanations and source links. Resolved checks do not offer Resolve, but tenant administrators can still select Re-run from the resolved check dialog to start another check.

If a check has never run, or the latest result is clear, global administrators see Run evidence check on the latest card to start a new check without opening a dialog. If a check fails, tenant administrators can select Re-run directly on the latest card (no modal required). You can also open a failed check and select Re-run from the dialog. After starting a check or re-run, the Evidence Checks section shows its running status and, when available, a description and step-by-step progress count. If you leave and return while a check is running, the section reconnects to its live progress. If the live status connection is interrupted, the section refreshes the latest result. Failed checks do not offer a resolve action.

Cloning a Guideline

Click the Clone action on a guideline row. A dialog asks you for a name for the copy. The clone inherits all rules, formulary assignments, and contact settings from the original. You can edit the clone independently after it is created.

Adopting from the Library

If your account has access to the Library tab (visible for most tenants), you can adopt pre-built guideline templates maintained by your organization’s global team.

  1. Click the Library tab at the top of the Guideline Configuration page.
  2. Browse or search the available templates.
  3. Click Adopt on any template you want to use. The system copies it into your Guidelines tab, where you can configure it for your business unit.