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Clinical content library

The library/ directory at the repository root is where all clinical coverage rules live. Each subdirectory is a self-contained module: a bundle of FHIR resources and CQL logic that defines when a rule fires, what documentation to collect, and what coverage determination to return.

Adding new rules does not require any Java code changes. Drop files into a new library/ subdirectory, restart the server, and the rule is active across CRD, DTR, and PAS.

How the pieces fit together

A PlanDefinition is the entry point. It declares which order codes trigger the rule, which payor IDs it applies to, and which CDS hooks activate it. The PlanDefinition points to a Library resource, which wraps a CQL file containing the actual logic. Does the rule apply? What should the card say? Is prior auth required?

For rules that need documentation collection, a Questionnaire defines what DTR asks the provider. ValueSets supply coded answer options.

What each use case needs

A CRD-only module (coverage cards, no documentation collection) needs three files:

  • PlanDefinition-*.json
  • Library-*.json
  • *.cql

A CRD + DTR module (coverage cards plus questionnaire) adds at least two more:

  • Questionnaire-*.json
  • ValueSet-*.json (one per coded answer list)

PAS works automatically. It reuses the same PlanDefinition and CQL to evaluate coverage for prior authorization requests.

Next steps