{
  "$schema": "https://json-schema.org/draft/2020-12/schema",
  "$id": "https://artifacts.apis.io/backworkhealth-com/json-schema/backworkhealth-com-prior-auth-check-schema.json",
  "title": "PriorAuthCheck",
  "x-generated": "2026-11-02",
  "x-method": "derived",
  "x-generator": "derive-json-schema.py",
  "x-source": "openapi/backworkhealth-com-v1-openapi.json#/components/schemas/PriorAuthCheck",
  "type": "object",
  "properties": {
    "pa_required": {
      "type": "boolean",
      "description": "Whether prior authorization is required"
    },
    "prior_auth_required": {
      "type": "boolean",
      "description": "Whether prior authorization is required"
    },
    "coverage_status": {
      "type": "string",
      "enum": [
        "covered",
        "conditional",
        "not_covered",
        "unknown"
      ]
    },
    "confidence": {
      "type": "string",
      "enum": [
        "high",
        "medium",
        "low"
      ]
    },
    "denial_risk": {
      "type": "string",
      "enum": [
        "low",
        "medium",
        "high"
      ]
    },
    "reason": {
      "type": "string",
      "description": "Explanation of the determination"
    },
    "matched_policies": {
      "type": "array",
      "items": {
        "type": "object",
        "properties": {
          "policy_id": {
            "type": "string"
          },
          "title": {
            "type": "string"
          },
          "policy_type": {
            "type": "string"
          },
          "jurisdiction": {
            "type": [
              "string",
              "null"
            ]
          },
          "source_url": {
            "type": [
              "string",
              "null"
            ]
          },
          "effective_date": {
            "type": [
              "string",
              "null"
            ]
          },
          "last_verified_at": {
            "anyOf": [
              {
                "type": "string",
                "format": "date-time"
              },
              {
                "type": "null"
              }
            ]
          },
          "applicability_scope": {
            "type": "string",
            "enum": [
              "shared_markets",
              "document_scoped"
            ]
          },
          "applicability_markets": {
            "description": "Markets whose publisher indexes list this exact document",
            "type": "array",
            "items": {
              "type": "string"
            }
          },
          "applicability_evidence": {
            "anyOf": [
              {
                "type": "object",
                "properties": {
                  "document_sha256": {
                    "type": "string",
                    "pattern": "^[0-9a-f]{64}$"
                  },
                  "market_index_listings": {
                    "maxItems": 16,
                    "type": "array",
                    "items": {
                      "type": "object",
                      "properties": {
                        "market": {
                          "type": "string",
                          "pattern": "^[A-Z]{2}$"
                        },
                        "index_url": {
                          "type": "string",
                          "maxLength": 2048,
                          "pattern": "^https:\\/\\/"
                        }
                      },
                      "required": [
                        "market",
                        "index_url"
                      ]
                    }
                  },
                  "document_statements": {
                    "maxItems": 16,
                    "type": "array",
                    "items": {
                      "type": "object",
                      "properties": {
                        "kind": {
                          "type": "string",
                          "enum": [
                            "non_medicare_disclaimer",
                            "commercial_policy_header",
                            "member_type_branch"
                          ]
                        },
                        "quote": {
                          "type": "string",
                          "minLength": 1,
                          "maxLength": 4000
                        },
                        "page": {
                          "type": "integer",
                          "exclusiveMinimum": 0
                        }
                      },
                      "required": [
                        "kind",
                        "quote",
                        "page"
                      ]
                    }
                  }
                },
                "required": [
                  "document_sha256",
                  "market_index_listings",
                  "document_statements"
                ]
              },
              {
                "type": "null"
              }
            ]
          },
          "applicability_note": {
            "description": "Explanation when shared or unscoped evidence does not establish a member's plan applicability",
            "type": [
              "string",
              "null"
            ]
          },
          "public_url": {
            "anyOf": [
              {
                "type": "string",
                "format": "uri"
              },
              {
                "type": "null"
              }
            ],
            "description": "Backwork's public page for this policy, or null when it has none. Active Medicare LCDs, Articles and NCDs: `https://backworkhealth.com/policy/{policy_id}`. Active commercial policies: `https://backworkhealth.com/policy/payer/{payer_slug}/{policy_id}`. A retired commercial policy points to its active successor's page when one is known."
          },
          "source_check": {
            "anyOf": [
              {
                "$ref": "#/$defs/SourceCheck"
              },
              {
                "type": "null"
              }
            ],
            "description": "Source provenance for this policy; null only when the policy is no longer on record."
          },
          "payer": {
            "anyOf": [
              {
                "$ref": "#/$defs/PolicyPayer"
              },
              {
                "type": "null"
              }
            ],
            "description": "The payer whose policy this is; null for Medicare evidence"
          },
          "codes": {
            "type": "array",
            "items": {
              "type": "object",
              "properties": {
                "code": {
                  "type": "string"
                },
                "code_system": {
                  "type": "string"
                },
                "disposition": {
                  "type": "string"
                },
                "condition_reference": {
                  "type": [
                    "string",
                    "null"
                  ]
                },
                "source": {
                  "$ref": "#/$defs/CodeSource"
                },
                "grounding": {
                  "$ref": "#/$defs/CodeGrounding"
                }
              },
              "required": [
                "code",
                "code_system",
                "disposition",
                "condition_reference",
                "source",
                "grounding"
              ]
            }
          }
        },
        "required": [
          "policy_id",
          "title",
          "policy_type",
          "jurisdiction",
          "source_url",
          "effective_date",
          "last_verified_at",
          "public_url",
          "source_check",
          "payer",
          "codes"
        ]
      }
    },
    "policy_sources": {
      "type": "array",
      "items": {
        "$ref": "#/$defs/PriorAuthPolicySource"
      }
    },
    "negotiated_rates": {
      "description": "Transparency in Coverage negotiated-rate summaries keyed by billing code, when available",
      "type": "object",
      "propertyNames": {
        "type": "string"
      },
      "additionalProperties": {
        "type": "object",
        "properties": {
          "min_rate": {
            "type": "string"
          },
          "max_rate": {
            "type": "string"
          },
          "avg_rate": {
            "type": "string"
          },
          "num_rates": {
            "type": "number"
          },
          "payer": {
            "type": "string"
          },
          "source": {
            "type": "string"
          },
          "payer_scope": {
            "type": "string"
          },
          "as_of": {
            "type": "string"
          },
          "billing_code_set": {
            "type": "string"
          },
          "is_current": {
            "type": "boolean"
          }
        },
        "required": [
          "min_rate",
          "max_rate",
          "avg_rate",
          "num_rates",
          "payer",
          "source",
          "payer_scope",
          "as_of",
          "billing_code_set",
          "is_current"
        ]
      }
    },
    "documentation_checklist": {
      "type": "array",
      "items": {
        "type": "string"
      },
      "description": "Required documentation items"
    },
    "documentation_requirements": {
      "type": "array",
      "items": {
        "type": "string"
      },
      "description": "Required documentation items for machine-readable coverage decisions"
    },
    "source_policy_references": {
      "type": "array",
      "items": {
        "$ref": "#/$defs/PriorAuthPolicySource"
      },
      "description": "Alias of policy_sources for coverage-decision clients."
    },
    "effective_date": {
      "type": [
        "string",
        "null"
      ]
    },
    "last_verified_at": {
      "anyOf": [
        {
          "type": "string",
          "format": "date-time"
        },
        {
          "type": "null"
        }
      ]
    },
    "requires_manual_review": {
      "type": "boolean"
    },
    "known_gaps": {
      "type": "array",
      "items": {
        "type": "string"
      }
    },
    "coverage_decision": {
      "type": "object",
      "properties": {
        "coverage_status": {
          "type": "string",
          "enum": [
            "covered",
            "conditional",
            "not_covered",
            "unknown"
          ]
        },
        "prior_auth_required": {
          "type": "boolean"
        },
        "documentation_requirements": {
          "type": "array",
          "items": {
            "type": "string"
          }
        },
        "denial_risk": {
          "type": "string",
          "enum": [
            "low",
            "medium",
            "high"
          ]
        },
        "policy_sources": {
          "type": "array",
          "items": {
            "$ref": "#/$defs/PriorAuthPolicySource"
          }
        },
        "effective_date": {
          "type": [
            "string",
            "null"
          ]
        },
        "last_verified_at": {
          "anyOf": [
            {
              "type": "string",
              "format": "date-time"
            },
            {
              "type": "null"
            }
          ]
        },
        "confidence": {
          "type": "string",
          "enum": [
            "high",
            "medium",
            "low"
          ]
        },
        "requires_manual_review": {
          "type": "boolean"
        },
        "known_gaps": {
          "type": "array",
          "items": {
            "type": "string"
          }
        }
      },
      "required": [
        "coverage_status",
        "prior_auth_required",
        "documentation_requirements",
        "denial_risk",
        "policy_sources",
        "effective_date",
        "last_verified_at",
        "confidence",
        "requires_manual_review",
        "known_gaps"
      ]
    },
    "criteria_details": {
      "type": "object",
      "properties": {
        "indications": {
          "type": "array",
          "items": {
            "type": "object",
            "properties": {
              "text": {
                "type": "string"
              },
              "tags": {
                "anyOf": [
                  {
                    "type": "array",
                    "items": {
                      "type": "string"
                    }
                  },
                  {
                    "type": "null"
                  }
                ]
              },
              "policy_id": {
                "type": [
                  "string",
                  "null"
                ]
              }
            },
            "required": [
              "text",
              "tags",
              "policy_id"
            ]
          }
        },
        "limitations": {
          "type": "array",
          "items": {
            "type": "object",
            "properties": {
              "text": {
                "type": "string"
              },
              "tags": {
                "anyOf": [
                  {
                    "type": "array",
                    "items": {
                      "type": "string"
                    }
                  },
                  {
                    "type": "null"
                  }
                ]
              },
              "policy_id": {
                "type": [
                  "string",
                  "null"
                ]
              }
            },
            "required": [
              "text",
              "tags",
              "policy_id"
            ]
          }
        },
        "pagination": {
          "description": "Absent when no policy matched",
          "type": "object",
          "properties": {
            "page": {
              "type": "integer"
            },
            "per_page": {
              "type": "integer"
            },
            "indications": {
              "type": "object",
              "properties": {
                "total": {
                  "type": "integer"
                },
                "total_pages": {
                  "type": "integer"
                },
                "has_next": {
                  "type": "boolean"
                },
                "has_previous": {
                  "type": "boolean"
                }
              },
              "required": [
                "total",
                "total_pages",
                "has_next",
                "has_previous"
              ]
            },
            "limitations": {
              "type": "object",
              "properties": {
                "total": {
                  "type": "integer"
                },
                "total_pages": {
                  "type": "integer"
                },
                "has_next": {
                  "type": "boolean"
                },
                "has_previous": {
                  "type": "boolean"
                }
              },
              "required": [
                "total",
                "total_pages",
                "has_next",
                "has_previous"
              ]
            },
            "documentation": {
              "type": "object",
              "properties": {
                "total": {
                  "type": "integer"
                },
                "total_pages": {
                  "type": "integer"
                },
                "has_next": {
                  "type": "boolean"
                },
                "has_previous": {
                  "type": "boolean"
                }
              },
              "required": [
                "total",
                "total_pages",
                "has_next",
                "has_previous"
              ]
            }
          },
          "required": [
            "page",
            "per_page",
            "indications",
            "limitations",
            "documentation"
          ]
        }
      },
      "required": [
        "indications",
        "limitations"
      ]
    },
    "mac": {
      "anyOf": [
        {
          "type": "object",
          "properties": {
            "name": {
              "type": "string"
            },
            "jurisdiction": {
              "type": "string"
            },
            "states": {
              "anyOf": [
                {
                  "type": "array",
                  "items": {
                    "type": "string"
                  }
                },
                {
                  "type": "null"
                }
              ]
            }
          },
          "required": [
            "name",
            "jurisdiction",
            "states"
          ]
        },
        {
          "type": "null"
        }
      ]
    }
  },
  "required": [
    "pa_required",
    "prior_auth_required",
    "coverage_status",
    "confidence",
    "denial_risk",
    "reason",
    "matched_policies",
    "policy_sources",
    "documentation_checklist",
    "documentation_requirements",
    "source_policy_references",
    "effective_date",
    "last_verified_at",
    "requires_manual_review",
    "known_gaps",
    "coverage_decision",
    "criteria_details",
    "mac"
  ],
  "$defs": {
    "CodeGrounding": {
      "type": "string",
      "enum": [
        "grounded",
        "not_grounded",
        "no_source_text",
        "not_checked"
      ],
      "description": "Whether Backwork found this code in the source text it retained for the policy. grounded: found in the retained source text. not_grounded: Backwork's document pipeline read the code, but it is not in the retained source text. no_source_text: Backwork retained no source text to check. not_checked: not checked; always the value for codes inferred from the policy title."
    },
    "CodeSource": {
      "type": "string",
      "enum": [
        "document",
        "inferred_title_match"
      ],
      "description": "document: listed in the payer's policy document. inferred_title_match: attached because the policy title names the drug; the document itself does not list the code."
    },
    "PolicyPayer": {
      "type": "object",
      "properties": {
        "name": {
          "type": "string"
        },
        "code": {
          "type": "string"
        },
        "slug": {
          "type": "string",
          "pattern": "^[a-z0-9]+(-[a-z0-9]+)*$",
          "description": "URL slug of the payer's public Backwork pages (`/policy/payer/{slug}`). Assigned once; never changes."
        }
      },
      "required": [
        "name",
        "code",
        "slug"
      ],
      "description": "The payer whose policy this is."
    },
    "PriorAuthPolicySource": {
      "type": "object",
      "properties": {
        "source_id": {
          "type": "string"
        },
        "policy_id": {
          "type": "string"
        },
        "title": {
          "type": "string"
        },
        "policy_type": {
          "type": "string"
        },
        "jurisdiction": {
          "type": [
            "string",
            "null"
          ]
        },
        "source_url": {
          "type": [
            "string",
            "null"
          ]
        },
        "effective_date": {
          "type": [
            "string",
            "null"
          ]
        },
        "last_verified_at": {
          "anyOf": [
            {
              "type": "string",
              "format": "date-time"
            },
            {
              "type": "null"
            }
          ]
        },
        "applicability_scope": {
          "type": "string",
          "enum": [
            "shared_markets",
            "document_scoped"
          ]
        },
        "applicability_markets": {
          "description": "Markets whose publisher indexes list this exact document",
          "type": "array",
          "items": {
            "type": "string"
          }
        },
        "applicability_evidence": {
          "anyOf": [
            {
              "type": "object",
              "properties": {
                "document_sha256": {
                  "type": "string",
                  "pattern": "^[0-9a-f]{64}$"
                },
                "market_index_listings": {
                  "maxItems": 16,
                  "type": "array",
                  "items": {
                    "type": "object",
                    "properties": {
                      "market": {
                        "type": "string",
                        "pattern": "^[A-Z]{2}$"
                      },
                      "index_url": {
                        "type": "string",
                        "maxLength": 2048,
                        "pattern": "^https:\\/\\/"
                      }
                    },
                    "required": [
                      "market",
                      "index_url"
                    ]
                  }
                },
                "document_statements": {
                  "maxItems": 16,
                  "type": "array",
                  "items": {
                    "type": "object",
                    "properties": {
                      "kind": {
                        "type": "string",
                        "enum": [
                          "non_medicare_disclaimer",
                          "commercial_policy_header",
                          "member_type_branch"
                        ]
                      },
                      "quote": {
                        "type": "string",
                        "minLength": 1,
                        "maxLength": 4000
                      },
                      "page": {
                        "type": "integer",
                        "exclusiveMinimum": 0
                      }
                    },
                    "required": [
                      "kind",
                      "quote",
                      "page"
                    ]
                  }
                }
              },
              "required": [
                "document_sha256",
                "market_index_listings",
                "document_statements"
              ]
            },
            {
              "type": "null"
            }
          ]
        },
        "applicability_note": {
          "description": "Explanation when shared or unscoped evidence does not establish a member's plan applicability",
          "type": [
            "string",
            "null"
          ]
        },
        "public_url": {
          "anyOf": [
            {
              "type": "string",
              "format": "uri"
            },
            {
              "type": "null"
            }
          ],
          "description": "Backwork's public page for this policy, or null when it has none. Active Medicare LCDs, Articles and NCDs: `https://backworkhealth.com/policy/{policy_id}`. Active commercial policies: `https://backworkhealth.com/policy/payer/{payer_slug}/{policy_id}`. A retired commercial policy points to its active successor's page when one is known."
        },
        "source_check": {
          "anyOf": [
            {
              "$ref": "#/$defs/SourceCheck"
            },
            {
              "type": "null"
            }
          ],
          "description": "Source provenance for this policy; null only when the policy is no longer on record."
        },
        "payer": {
          "anyOf": [
            {
              "$ref": "#/$defs/PolicyPayer"
            },
            {
              "type": "null"
            }
          ],
          "description": "The payer whose policy this is; null for Medicare evidence"
        }
      },
      "required": [
        "source_id",
        "policy_id",
        "title",
        "policy_type",
        "jurisdiction",
        "source_url",
        "effective_date",
        "last_verified_at",
        "public_url",
        "source_check",
        "payer"
      ]
    },
    "SourceAccuracy": {
      "type": "object",
      "properties": {
        "field": {
          "type": "string",
          "enum": [
            "overall",
            "title",
            "effective_date",
            "codes",
            "link"
          ],
          "description": "What the audit measured: `overall` for the policy record as a whole, or one field of it (`title`, `effective_date`, `codes`, `link`)."
        },
        "sampled_at": {
          "type": "string",
          "format": "date-time",
          "description": "When the audit drew its sample."
        },
        "sample_size": {
          "type": "integer",
          "exclusiveMinimum": 0,
          "description": "How many of this source's policy records the audit sampled."
        },
        "accuracy": {
          "type": "number",
          "minimum": 0,
          "maximum": 1,
          "description": "Share of the sampled records whose `field` matched the source document, from 0 to 1: the records that matched divided by `sample_size`."
        },
        "ci_low": {
          "type": "number",
          "minimum": 0,
          "maximum": 1,
          "description": "Lower bound of the 95% Wilson score confidence interval for `accuracy`."
        },
        "ci_high": {
          "type": "number",
          "minimum": 0,
          "maximum": 1,
          "description": "Upper bound of the 95% Wilson score confidence interval for `accuracy`."
        },
        "method": {
          "type": "string",
          "description": "How the audit decided whether a sampled record matched its source, as Backwork names the method."
        }
      },
      "required": [
        "field",
        "sampled_at",
        "sample_size",
        "accuracy",
        "ci_low",
        "ci_high",
        "method"
      ],
      "description": "The most recent audit of one field for the policy's source. It measures a sample of the source's policy records, not this policy alone."
    },
    "SourceCheck": {
      "type": "object",
      "properties": {
        "source_url": {
          "type": "string",
          "description": "The URL Backwork fetches this policy from."
        },
        "last_fetched_at": {
          "anyOf": [
            {
              "type": "string",
              "format": "date-time"
            },
            {
              "type": "null"
            }
          ],
          "description": "When Backwork last fetched the policy from `source_url`; null when no fetch time is recorded. The payer may have changed the document since."
        },
        "content_sha256": {
          "anyOf": [
            {
              "type": "string",
              "pattern": "^[0-9a-f]{64}$"
            },
            {
              "type": "null"
            }
          ],
          "description": "SHA-256 of the content Backwork fetched, as 64 lowercase hex characters; null when the loader did not record one. Compare it across responses to see whether the fetched content changed."
        },
        "source_accuracy": {
          "anyOf": [
            {
              "type": "array",
              "items": {
                "$ref": "#/$defs/SourceAccuracy"
              }
            },
            {
              "type": "null"
            }
          ],
          "description": "The latest audit for each field Backwork has audited for this policy's source, `overall` first. null when the policy has no recorded source or its source has no audit yet."
        }
      },
      "required": [
        "source_url",
        "last_fetched_at",
        "content_sha256",
        "source_accuracy"
      ],
      "description": "Where and when Backwork last fetched this policy, a hash of the fetched content, and the sampled accuracy that audits measured for its source."
    }
  }
}