Business rules - Commure Documentation

Business rules are automated checks that run when a referral is processed. They evaluate the referral’s data against configured rules and determine eligibility, routing decisions, and payor priority.

What business rules evaluate

Rule type	Description
Do Not Readmit	Checks patient name + DOB against the DNR list. Passes if the patient is not found in the list.
Service area	Determines whether the requested disciplines are available at the patient’s location.
Eligibility	Runs eligibility through Waystar and Availity.
Payor scorecards	Scores payors by how desirable they are.
Branch NPIs	Validates that the NPI on the referral matches a known branch.
Partnered referral sources	Identifies whether the referring provider or facility is a known partner.

When rules run

Business rules run automatically during referral processing (even before the Pending status). They also are re-triggered automatically if any dependent data changes (e.g. if zip code is updated, Service Area will be re-checked).

Business rule configuration is managed by administrators. Coordinators can view rule results but cannot modify the rules themselves.

Eligibility

As part of business rule processing, the system runs an eligibility check against the patient’s insurance information. The eligibility summary is visible in the referral detail view and shows:

Whether the patient is eligible for the requested services
Key insurance details extracted and verified
Any flags or issues that require manual review