Turn clinical guidelines into actionable prior authorization criteria.
CriteriaBuilder helps Health Plans and PBMs transform clinical guidelines, medical policies, formulary rules, and payer-specific requirements into structured criteria, question sets, decision paths, and approval workflows inside PAHub.
Built for high-volume prior authorization operations, CriteriaBuilder helps teams reduce manual criteria buildout, standardize review logic, accelerate policy updates, and support more consistent, defensible decisioning across medical and pharmacy utilization management.
Automate clinical criteria buildout without losing control.
Prior authorization teams rely on complex clinical criteria, policy rules, formulary requirements, and documentation standards. Maintaining those rules manually can slow operations, introduce variability, and make policy updates harder to scale.
CriteriaBuilder is designed to convert clinical guidelines and policies into structured criteria, question sets, automated rules, and guided reviewer workflows. That structured logic can then be used across PAHub to support intake, review, auto-decisioning, routing, documentation, and reporting.
- Translate clinical policies into structured PA workflows.
- Support medical and pharmacy benefit authorization criteria.
- Standardize the reviewer experience across teams and lines of business.
- Improve consistency, speed, audit readiness, and operational scalability.
From guideline to operational workflow.
CriteriaBuilder helps transform source criteria into usable prior authorization logic that can support reviewers, automation, reporting, and compliance workflows.
Ingest Criteria
Start with medical policies, CMS Guidelines, MCG, InterQual, formulary requirements, or payer-specific criteria.
Structure Logic
Convert narrative requirements into clinical questions, decision paths, documentation requirements, and approval rules.
Configure Workflow
Align criteria with lines of business, benefit type, routing rules, clinical review workflows, and reviewer guidance.
Apply in PAHub
Use structured criteria to support auto-adjudication, guided review, consistent documentation, and audit-ready reporting.
Support the criteria sources your teams already use.
CriteriaBuilder can help convert external guidelines, internal policies, formulary requirements, and plan-specific rules into structured workflows that fit your operations.
Whether teams are building clinical criteria for medical procedures, medical benefit drugs, pharmacy benefit medications, step therapy, quantity limits, or formulary exceptions, CriteriaBuilder helps bring speed and consistency to the process.
CMS Guidelines
Support regulatory readiness with criteria that can align to CMS expectations and PA transparency needs.
MCG / InterQual
Structure evidence-based guidelines into review logic and guided workflows.
Payer-Specific Criteria
Configure plan-specific policies, lines of business, benefit designs, and operational rules.
CriteriaBuilder is part of PAHub’s automated decision engine.
CriteriaBuilder does not operate in isolation. It feeds structured clinical logic into PAHub so prior authorization workflows can connect criteria, data extraction, FHIR readiness, reviewer guidance, auto-decisioning, and reporting.
CriteriaBuilder
Converts clinical guidelines and policies into structured criteria, question sets, and workflows.
ClinIntel
Extracts and interprets unstructured clinical data to power intelligent decision automation.
FHIR / CMS-0057
Supports standardized data exchange, transparency, status tracking, and interoperability readiness.
Designed for criteria-driven PA operations.
CriteriaBuilder helps teams manage complex criteria across medical and pharmacy utilization management while maintaining consistency, configurability, and control.
Medical Services
Structure criteria for medical procedures, imaging, DME, oncology, inpatient, outpatient, and aftercare services.
Pharmacy Benefit PA
Build criteria for retail drugs, specialty medications, step therapy, quantity limits, and formulary exceptions.
Policy Maintenance
Update criteria when clinical policies, formulary decisions, or P&T requirements change.
Audit Readiness
Support consistent documentation of criteria used, decision logic, reviewer actions, timestamps, and outcomes.
Build criteria faster. Apply them more consistently.
CriteriaBuilder supports the operational foundation needed for faster, more accurate, and more compliant prior authorization workflows.
- Reduce manual effort required to convert policies into workflows.
- Improve consistency across reviewers, departments, and benefit types.
- Support more auto-adjudication when criteria are clearly met.
- Route complex cases to the right reviewers with the right guidance.
- Strengthen auditability with structured criteria and documentation.
Modernize clinical criteria automation with PAHub CriteriaBuilder.
See how Agadia helps Health Plans and PBMs convert clinical criteria into structured workflows that support faster, more defensible prior authorization decisions.