How It Works

A governed evidence-readiness pipeline.

Scroll through the operator-controlled workflow that matches SEDONA today: no-PHI intake, case-scoped policy research, evidence review, confidence scoring, binder assembly, and partner handoff before submission.

  1. PHASE 01 operator gated

    No-PHI Case Intake

    The operator enters payer, CPT/HCPCS, diagnosis code, procedure, state, product line, and optional public or authorized sources. SEDONA runs a local PHI preflight before any model or network call and rejects unsafe input by class, not value.

    PHI preflight Human-controlled launch
  2. PHASE 02 live preview

    Case-Scoped Policy Research

    SEDONA resolves the selected payer against its routing profiles, then reviews public or authorized policy sources for that case only. The engine records source URLs, source classifications, and blocked-source notes instead of crawling broadly or logging into portals.

    Payer routing profiles Source-linked findings
  3. PHASE 03 evidence pass

    Evidence Intelligence

    The evidence layer extracts medical-necessity criteria, documentation gaps, payer-specific requirements, and source provenance. If public evidence is weak or blocked, SEDONA fails closed and asks for human or partner source assist.

    Evidence extraction Fail-closed gaps
  4. PHASE 04 governed scoring

    Readiness Scoring

    The shared engine returns evidence status, confidence score, criteria count, missing-evidence count, risk flags, and sources checked. The public workflow shows readiness and gaps without exposing credentials, infrastructure, or unsupported determination claims.

    Confidence score Evidence status
  5. PHASE 05 human review

    Binder Assembly

    The app assembles findings, source links, an admin run log, an optional appeal draft, and a verifiable evidence manifest for human review. Nothing is auto-submitted; SEDONA always returns a no-submit contract.

    Evidence binder Verifiable manifest
  6. POST-RUN outcome feedback

    Partner Handoff

    For partner workflows, SEDONA returns readiness, missing documentation, source provenance, and a handoff recommendation while the partner or hospital system keeps submission, status, and determination ownership.

    Submission allowed: false Human review required

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