Rules Engine & Automation Logic
The Medecision Platform leverages a robust, highly configurable rules engine and automation framework to power intelligent workflows across care management, utilization management, clinical intelligence, digital engagement, and appeals & grievances. This section provides a comprehensive explanation of the underlying rules infrastructure, logic types, builder tools, and common use cases.
Core Design Principles
The platform's automation engine is governed by the following principles:
Declarative Configuration: Rules are managed using no-code visual builders.
Real-Time Execution: Triggered instantly based on data updates, API calls, or user actions.
Auditability: All logic evaluations and results are recorded.
Environment Promotion: Rules follow lifecycle stages (dev → test → prod) with version control.
Rules Engine Capabilities
The rules engine can evaluate data from multiple sources and execute logic-driven actions across all core modules.
Supported Rule Inputs:
Claims, labs, SDOH, assessments
ADT messages and encounter data
Intake forms (e.g., guided UM intake)
FHIR API payloads
Member demographics and eligibility
Supported Actions:
Create or update programs, tasks, requests
Trigger or suppress correspondence
Assign tasks based on roles or availability
Auto-decision prior auths or appeals
Escalate to supervisory queues
Launch or terminate outreach campaigns
Types of Rules
1. Trigger Rules
Execute actions in response to an event or data change.
Example:
IF event = ADT Admit AND Dx = CHFTHEN auto-enroll in TOC Program and assign CM outreach task
2. Eligibility Rules
Determine if a member qualifies for a program or workflow.
Example:
IF Age > 65 AND Risk Score > 6 AND NOT in Program XTHEN Enroll in Complex Care Management Program
3. Scoring Rules
Assign risk scores based on weighted logic.
Example:
+3 if Dx = COPD, +2 if recent admit, +5 if no PCP visit in 12 monthsTotal score > 8 → high risk
4. Routing Rules
Assign tasks or requests based on internal operational logic.
Example:
IF request type = MH/SUD AND region = NortheastTHEN assign to Behavioral Health queue
5. TAT & SLA Rules
Monitor turnaround times and trigger escalations.
Example:
IF request unresolved after 48 hrs AND urgent = trueTHEN escalate to medical director and notify compliance
Builders Overview
Rules and automations are configured using a suite of visual builders.
Builder | Purpose |
Rules Builder | Core logic engine for trigger/action-based rules |
Program Builder | Eligibility, staging, and completion logic for programs |
Task Builder | Task assignment, deadlines, recurrence rules |
Assessment Builder | Branching logic and score-based follow-up actions |
Campaign Builder | Digital outreach segmentation and sequencing |
TAT Builder | TAT compliance logic and escalation paths |
Each builder:
Uses visual drag-and-drop or dropdown logic configuration
Is version-controlled and testable
Supports rollback and governance promotion
Execution Architecture
Rules are executed as part of the event processing pipeline:
Event Occurs (data ingestion, API call, UI submission)
Rule Engine Evaluates all matching rules
Actions Executed if rule conditions met
Results Logged for audit and display
Execution may be synchronous (UI action) or asynchronous (data feed processing).
Examples by Module
Care Management
Auto-enroll in program when new diagnosis is detected
Assign outreach task when member completes self-assessment
Launch campaign when gaps in care detected
Utilization Management
Auto-decision DME requests with all clinical criteria met
Route requests with Dx = high cost to MD review
Trigger reminder tasks at 24-hour and 48-hour TAT checkpoints
Appeals & Grievances
Escalate expedited appeal if 48-hour window is approaching
Auto-close grievance if member call resolved the issue and no formal complaint is logged
Digital Engagement
Send SMS reminder if task not completed within 7 days
Suppress second message if member opens email within 24 hours
Auditing & Governance
Every rule execution and action is logged in the platform:
Member timeline records action and reason
Audit logs track who created/edited logic
Each rule execution traceable with input, output, and action path
Governance workflows include:
Role-based access to builders
Multi-environment promotion (dev, staging, prod)
Change review/approval prior to deployment
Best Practices
Use naming conventions to categorize rules (e.g., UM-AutoDecision-DME)
Group rules into logical sets to simplify troubleshooting
Document rule intent and logic assumptions in builder description fields
Test logic with known datasets before enabling in production
The rules engine and automation capabilities are central to the Medecision Platform’s scalability, regulatory compliance, and staff efficiency. Combined with modular builders and real-time execution, they support dynamic workflows tailored to each organization’s population, operations, and clinical goals.