Running Guideline Evaluations
A guideline evaluation runs a set of clinical rules against a population of patients in your business unit. You can run evaluations in Report mode to analyze results without creating tasks, or in Active mode to trigger real prior-authorization workflows.
GoldCard, Therapeutic Interchange, and Legacy Therapy Discontinuation configs are different: they do not use Play / Run Guideline from the list or detail page. Matching runs automatically each day for enabled configs. Use Guideline Manager to create or edit the config; then rely on the daily check rather than a manual evaluation dialog.
On a GoldCard, Therapeutic Interchange, or Legacy Therapy Discontinuation detail page, an info banner at the top explains the scheduled behavior. For GoldCard, members who clearly match the matching rules are put through prior authorization automatically, while members with missing data are left alone. For Therapeutic Interchange, the daily scheduled run finds members on the source drug in the selected population and applies continuation-style interchange rules. Members who meet the rules have a source authorization queued (no letter is sent). Members who fail have a 30-day refill block queued and receive a required prescriber move-to-preferred notice; patient and pharmacy notices are optional. Members with missing data receive a therapeutic interchange data request, and an expired request queues the same refill block. Members with an interchange already in progress are not contacted again, members who have moved to the preferred drug are not revisited, and members who were reviewed without a new episode are left alone for about three months.
Legacy Therapy Discontinuation runs on the same daily schedule and the same continuation-style criteria, with a different ending. Members who meet the criteria stay on the therapy and have a source authorization queued. Members who fail are taken off that therapy with no replacement drug: a 30-day refill block is queued and the prescriber receives a required discontinuation notice, with patient and pharmacy notices optional. Members with missing data receive a legacy therapy data request, and an expired request queues the same refill block. Nothing in this program names a preferred or target drug.
Triggering an Evaluation
You can trigger an evaluation from the guideline’s detail page or from a patient’s chart (wherever the Run Guideline button appears). Standard guidelines and exclusions (where applicable) support this path. GoldCard, Therapeutic Interchange, and Legacy Therapy Discontinuation configs do not show Play / Run on the Guidelines list.
- Open the guideline you want to evaluate.
- Click Run Guideline. A dialog opens.
Evaluation Mode
Select one of:
- Active — the evaluation runs live. Patients who meet the criteria generate prior-authorization tasks, and contact with prescribers, patients, and pharmacies occurs according to the guideline’s contact settings.
- Report — the evaluation runs in analysis mode only. No tasks are created and no outreach is sent. Use this to preview which patients would be affected before committing to an Active run.
Evaluation Type
Evaluation Type applies to standard guidelines only.
For standard guidelines, select one of:
- Auto — the system detects from each patient’s claim evidence whether initiation or continuation rules apply. Use this for population-wide runs. Patients already on current therapy may be skipped for initiation (rules not run); see Not Evaluated on the evaluation results page.
- Initiation — evaluates only the initiation rules. Suitable for patients who are starting therapy.
- Continuation — evaluates only the continuation rules. Suitable for patients who are already on the medication and approaching a renewal.
When Auto is selected, patients on current therapy are typically skipped for initiation unless you switch to Initiation and enable Force evaluation (ignore PA and therapy requirements).
Contact Settings (Active mode only)
When you select Active mode, additional dropdowns appear for Prescriber Contact, Patient Contact, and Pharmacy Contact. These override the guideline’s default contact settings for this run only.
Also evaluate other indications
If the guideline targets a drug with multiple indications, you can check Also evaluate other indications for the same drug to include all related guidelines in a single multi-guideline evaluation.
Click Run to start the evaluation.
Viewing Batch Evaluations
All evaluations — past and in progress — appear in the batch evaluations list.
Tenant and global administrators — Open Manage Tenant (or Tenant Management), then select the Guideline Evaluations tab.
Other users who can edit guidelines — From the Settings gear menu, select Guideline Evaluations.
The table shows:
| Column | What it tells you |
|---|---|
| Status | Pending / Running / Completed / Failed |
| Guideline | The guideline that was evaluated (links to the guideline detail) |
| Mode | Report or Live |
| Created | When the evaluation was triggered |
| Completed | When it finished |
Click any row to open the evaluation’s detail page.
Monitoring Evaluation Progress
A running evaluation shows a progress bar in the Status column. The bar fills as the system processes patients. For large populations this may take several minutes.
Refresh the page or wait — the table updates automatically when the evaluation completes.
Reviewing Patient Results
Open a completed evaluation to see the full results.
Standard guidelines
Summary cards show totals including Not Evaluated (patients whose rules were skipped, for example because they are on current therapy in Auto mode or their business unit is excluded from the applicable phase), Initiation Matches, Initiation Rejections, Continue Therapy, Discontinue Therapy, Current Therapy, Data Requests, and Tasks Created.
When selected patients were skipped, the information banner above Patient Results reflects the reasons in that run. A current-therapy-only run explains that initiation rules were not run and mentions Force evaluation. A business-unit phase exclusion does not suggest Force evaluation because that setting does not override the carve-out. If patients were skipped for different reasons, the banner directs you to each row in Not Evaluated for the specific reason.
The Patient Results tabs list patients by outcome:
| Tab | What it shows |
|---|---|
| Initiation Matches | Patients who passed initiation rules |
| Continuation Matches | Patients who should continue therapy |
| Data Requests | Patients missing required data |
| Rejections | Patients who failed initiation with PA rejections |
| Not Evaluated | Patients whose rules were skipped, including current-therapy and business-unit phase exclusions |
Each row shows the patient’s name (links to their chart), Current Therapy, Initiation Match, PA Rejections, and skip reason where applicable. When a business-unit phase exclusion stopped evaluation before therapy detection, Current Therapy and Initiation Match show N/A rather than a definitive result. Click a patient row to jump to their chart.
Therapeutic Interchange
When the daily check runs an enabled Therapeutic Interchange config, the resulting evaluation appears in the batch evaluations list like any other batch run. Interchange results use therapeutic-interchange vocabulary instead of prior-authorization labels:
| Summary card | What it means |
|---|---|
| Evaluated | Sub-label: On source drug (TI rules run) — the count of patients who were on the source drug and had interchange rules applied to them. This is the actively-evaluated population. |
| Not Evaluated | Sub-label: Not on the source drug — patients in the population who are not on the source drug. Interchange rules are not run for them. They appear in the Not Evaluated tab with the reason “Not on the source drug.” |
| Stay on Source | Rules met — the member may remain on the source drug, and a source authorization is queued |
| Move to Target | Rules failed — the member must move to the preferred drug, and a 30-day refill block is queued |
| Data Requests | Missing data — a therapeutic interchange data request was sent |
| On Source Drug | Members currently on the source drug |
| Tasks Created | Interchange parent tasks created for fail or data-request outcomes (zero in Report mode) |
Continuation cards do not appear — interchange does not evaluate continuation therapy.
Configuration cards also differ: Evaluation Type and Force Initiation are hidden. Pharmacy Outreach shows whether pharmacy move-to-preferred letters were enabled for the run (Not enabled / no letters sent when pharmacy outreach was not configured on the interchange).
The Patient Results tabs are:
| Tab | What it shows |
|---|---|
| Stay on Source | Patients who met the rules and may remain on the source drug |
| Data Requests | Patients who need additional clinical data before a stay-on-source or move-to-target decision |
| Move to Target | Patients whose rules failed and whose 30-day refill block was queued |
| Not Evaluated | Patients not on the source drug — interchange rules were not run for them |
Each row in the Not Evaluated tab displays the reason “Not on the source drug” (not a skip due to PA or therapy requirements). Each row in the other tabs shows On Source Drug and an Outcome column using the queue and clinical-information labels above. Source Authorization Pending appears when the rules passed but the queue step still needs to finish. An expired request reads Data Request Expired — 30-Day Refill Block Queued. Older evaluations keep explicit historical stay, fail, or conversion-candidate labels. The PA Rejections column is not shown. Click a patient row to jump to their chart.
Legacy Therapy Discontinuation
A daily Legacy Therapy Discontinuation run appears in the batch evaluations list the same way, with its own vocabulary. Nothing on this page refers to a preferred or target drug:
| Summary card | What it means |
|---|---|
| Evaluated | Sub-label: On source drug (continuation criteria run) — patients who were on the source drug and had the continuation criteria applied. |
| Not Evaluated | Sub-label: Not on the source drug — patients in the population who are not on the source drug. The criteria are not run for them, and they appear in the Not Evaluated tab with the reason “Not on the source drug.” |
| Continue Therapy | Criteria met — the member stays on this therapy and a source authorization is queued |
| Discontinue Therapy | Criteria not met — the therapy ends with no replacement drug and a 30-day refill block is queued |
| Data Requests | Missing data — a discontinuation data request was sent |
| On Source Drug | Members currently on the source drug |
| Tasks Created | Discontinuation parent tasks created for fail or data-request outcomes (zero in Report mode) |
Continuation cards do not appear, and Evaluation Type and Force Initiation are hidden, the same as for Therapeutic Interchange. Pharmacy Outreach shows whether pharmacy discontinuation notices were enabled for the run.
The Patient Results tabs are Continue Therapy, Data Requests, Discontinue Therapy, and Not Evaluated. Each row shows On Source Drug and an Outcome column reading Continue Therapy, Continue Therapy — Source Authorization Queued, Clinical Information Requested, Discontinue Therapy — 30-Day Refill Block Queued, or Data Request Expired — 30-Day Refill Block Queued, with Pending variants while a queue step is still finishing. The PA Rejections column is not shown. Click a patient row to jump to their chart.