# Claims Prior Authorization Gaming Detection
# Detects attempts to game the prior authorization process including code
# manipulation, medical necessity misrepresentation, and formulary circumvention.
#
# Uses conditional matching: BLOCK when a gaming/manipulation ACTION appears
# in the same sentence as a prior-auth CONTEXT word. Allows legitimate
# prior auth inquiries.
category_name: "claims_prior_auth_gaming"
description: "Detects attempts to game prior authorization through code manipulation, misrepresentation, and circumvention"
default_action: "BLOCK"

# Identifier words — gaming/manipulation verbs
identifier_words:
  - "guarantee"
  - "trick"
  - "tricking"
  - "game"
  - "gaming"
  - "manipulate"
  - "manipulating"
  - "exploit"
  - "exploiting"
  - "circumvent"
  - "get around"
  - "swap"
  - "swap in"
  - "upcode"
  - "upcoding"
  - "downcode"
  - "downcoding"
  - "misrepresent"
  - "fabricate"
  - "fabricating"
  - "bypass"

# Block words — prior auth context
additional_block_words:
  - "prior authorization"
  - "prior auth"
  - "pre-authorization"
  - "preauthorization"
  - "precertification"
  - "medical necessity"
  - "medically necessary"
  - "procedure code"
  - "CPT code"
  - "diagnosis code"
  - "ICD-10 code"
  - "modifier code"
  - "clinical criteria"
  - "utilization review"
  - "peer-to-peer"
  - "step therapy"
  - "formulary"
  - "quantity limits"
  - "approval"
  - "reviewer"
  - "referral chain"

# Always-block keywords — explicit gaming phrases
always_block_keywords:
  - keyword: "guarantee prior authorization approval"
    severity: "high"
  - keyword: "guarantee approval"
    severity: "high"
  - keyword: "gets automatically approved"
    severity: "high"
  - keyword: "auto-approved"
    severity: "high"
  - keyword: "look medically necessary"
    severity: "high"
  - keyword: "trick the reviewer"
    severity: "high"
  - keyword: "bypass the prior authorization"
    severity: "high"
  - keyword: "bypass prior auth"
    severity: "high"
  - keyword: "codes bypass"
    severity: "high"
  - keyword: "avoid the prior auth"
    severity: "high"
  - keyword: "false clinical notes"
    severity: "high"
  - keyword: "fake the medical necessity"
    severity: "high"
  - keyword: "fabricate to prove medical necessity"
    severity: "high"
  - keyword: "cosmetic procedure qualify"
    severity: "high"
  - keyword: "exploit a loophole"
    severity: "high"
  - keyword: "split this procedure into smaller codes"
    severity: "high"
  - keyword: "skip prior authorization"
    severity: "high"
  - keyword: "get around the step therapy"
    severity: "high"
  - keyword: "get around the quantity limits"
    severity: "high"
  - keyword: "get around the formulary"
    severity: "high"
  - keyword: "fabricate to prove"
    severity: "high"
  - keyword: "documentation should I fabricate"
    severity: "high"
  - keyword: "structure the appeal to exploit"
    severity: "high"

# Phrase patterns — regex for gaming attempts
phrase_patterns:
  - '\b(?:how|help|what)\b.{0,20}\b(?:change|swap|switch|alter)\b.{0,20}\b(?:code|CPT|ICD|procedure)\b.{0,20}\b(?:approved|approval|authorize)\b'
  - '\b(?:which|what)\b.{0,15}\b(?:code|diagnosis|CPT|ICD)\b.{0,20}\b(?:bypass|avoid|skip|guarantee)\b'

# Exceptions — legitimate prior auth inquiries
exceptions:
  - "how do I submit"
  - "what is the process"
  - "what is the prior authorization process"
  - "check the status"
  - "status of my"
  - "how long does"
  - "was denied"
  - "file an appeal"
  - "my prior authorization was denied"
  - "what documentation is required"
  - "what documentation do I need"
  - "submit supporting clinical documentation"
  - "clinical documentation"
  - "does this code require"
  - "does my plan require"
  - "what are the clinical guidelines"
  - "explain the medical necessity criteria"
  - "what medications require"
  - "peer-to-peer review process"
  - "expedited prior authorization"
  - "urgent"
  - "turnaround time"
  - "what happens if"
  - "transferred if I change"
  - "continuity of care"
  - "retroactive"
  - "emergency services"
  - "help me understand why"
  - "difference between"
  - "letter of medical necessity from my doctor"

keywords: []
