Stanford Med · Unit 5B Medicine·Day shift·Mon · 9:42 AM

Coverage & Resource Matching

Michael Johnson · BlueShield MA Advantage HMO

RecommendationConfidence 0.91 · 3 alternates considered

Best match: Bayview Skilled Nursing

In-network for BlueShield MA Advantage · bed likely available Mon AM · accepts CHF cardiac rehab pathway · 4.2 miles from caregiver Carla · CMS 5-star: 4.2 · prior auth pre-validated via payer-rules.ts (no override needed).

Patient needs

Michael Johnson · CHF exacerbation (I50.9)

BlueShield MA Advantage HMOIn-network preferredCaregiver: Carla (POA) · 4mi

Post-acute

Short-term skilled rehab (7d)

Rev 0191

Education

CHF self-care + Entresto teaching

—

DME

Rolling walker + bedside scale

HCPCS E0143 / E0244

Medication

Entresto 49/51 mg BID (PA req)

NDC 00078-0659

Transport

Non-emergency wheelchair van

HCPCS A0130

Coverage matrix

BlueShield MA Advantage · plan rules

Item	Code	Tier	Copay	PA status	Decision due
Entresto 49/51 mg BID	NDC 00078-0659	Tier 3	$47/30d	submitted	Tue 09:00 AM
Furosemide 40 mg	NDC 00603-3743	Tier 1	$0	approved	—
Skilled rehab 7-day	Rev 0191	PA req	$0 (Day 1–20)	needed	—
Rolling walker	HCPCS E0143	DMEPOS	20% coins.	approved	—
Bedside scale	HCPCS E0244	DMEPOS	20% coins.	needed	—
NEMT wheelchair van	HCPCS A0130	Plan benefit	$0 (4 rides/mo)	approved	—

Matching resources

Ranked by payer fit · capacity · quality · caregiver distance · preference

11 candidates

Resource / provider	Type	Distance	In-network	Capacity	Quality	Preference match	Documents required
Bayview Skilled NursingBest match	SNF	4.2 mi	In-network	open	★ 4.2	Top match	SNF referral packet · Auth approval · MD orders
Hillcrest Rehab & Nursing	SNF	7.8 mi	In-network	limited	★ 3.8	Alternate	SNF referral packet · Auth approval
Marin Manor Post-Acute	SNF	12.4 mi	In-network	open	★ 3.5	Alternate	SNF referral packet
VNA Bay Area	Home Health	—	In-network	open	★ 4.4	Top match	HH referral · F2F encounter note
Lincare Home OxygenWalker + scale	DME	—	In-network	limited	★ 4.0	Top match	CMN form 484 · Rx
Apria Healthcare (backup)	DME	—	In-network	open	★ 3.9	Alternate	CMN form 484 · Rx
ModivCare NEMT	Transport	—	In-network	open	★ 3.9	Top match	Transport auth
CVS Pharmacy — Mission St	Pharmacy	1.4 mi	In-network	open	★ 4.1	Top match	Rx · PA approval
Walgreens — 24th St	Pharmacy	2.1 mi	In-network	open	★ 4.0	Alternate	Rx · PA approval
Mission Meals (CHF diet)Low-sodium	Community / SDOH	—	Out-of-network	open	★ 4.2	Top match	SDOH referral
Stanford Cardiac Rehab Phase II	Community / SDOH	5.3 mi	In-network	limited	★ 4.6	Alternate	Referral · Stress test

⚙How this screen works

Single pane for payer + resource alignment · pre-validates before submission

Inputs

What this screen reads

Patient's verified plan (X12 271 response · Availity)
Need list from cockpit (Entresto + walker + SNF rehab + NEMT)
Resource Hub directory (curated + live capacity feeds)
Payer rules library (src/lib/coverage/payer-rules.ts)

Engine

What it computes

Deterministic matcher: intersects payer × distance × capability × capacity × preference
AI tie-breaks ranking + writes rationale via runAgent
Pre-validates PA criteria against payer-rules library before submission

Outputs

What it writes / routes

Recommended best match with one-click Send referral
Auto-drafted PA packet ready for pharmacist review
Submission row per outbound vendor / payer action
Cockpit barriers update when match status changes

Refresh trigger

When it updates

Naviguide capacity feed (5 min)
Surescripts formulary update (8 min)
Eligibility refresh on plan change
Operator changes patient context (?patient= param)

Partners involved:Availity (eligibility)CoverMyMeds (Rx PA)Naviguide (SNF capacity + referral)Surescripts (formulary)Lincare / Apria / Parachute (DME)ModivCare / Uber Health (NEMT)

Demo data · no PHI · mocked Epic + payer endpoints