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.Documentation Index
Fetch the complete documentation index at: https://docs.patient-experience.commure.com/llms.txt
Use this file to discover all available pages before exploring further.
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