Payer policy intelligence
See every payer policy infull spectrum.
Prisym tracks the medical, prior authorization, and payment policies of 1,200+ payers and delegated entities and turns them into one searchable library. Ask for a therapy and get coverage across every payer, the criteria behind it, and the last revision that changed the answer.
- 20,000+ policies indexed
- Monitored daily for change
- Every version kept, nothing overwritten
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Payer policies indexed and growing
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Payers, government programs, and delegated entities
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Policy types, from medical policies to fee schedules
Daily
Monitoring cadence for fast-moving payers
Why Prisym
Every payer has coverage rules. Keeping up with all of them was the problem. Each payer decides what it will cover and what it needs to see first, in its own format, revised whenever it likes. Prisym tracks them all, keeps every version, and hands your team the answer for the patient in front of them.
The problem
The rules exist. They are just impossible to follow by hand.
Four ways payer policy quietly costs a team time and approvals.
- Scattered
Policies come from 1,200 different payers.
Commercial plans, state programs, and delegated vendors like Evicore and Carelon each write their own rules. Nobody has a single list.
- Silent
Revisions land without notice.
A criterion is added, an indication is dropped, a code moves. The first sign is usually a denial weeks later.
- Buried
The criteria are buried in 40-page policies.
What the payer needs to see is in there. Finding it for the right plan, line of business, and state takes an afternoon.
- Unrecorded
No one can prove what was in effect on the date of service.
Payers replace their own policies without a trace. When a claim is disputed, the version that applied is often gone.
The product
One question. Every payer.
Name a therapy and Prisym returns the coverage matrix: covered, covered with criteria, or not covered, for every payer you track, with the governing policy one click away and a determination for the patient in front of you.
Search a therapy across every payer
| Payer | Policy | Coverage | Updated |
|---|
Oncology Imaging · PSMA PET
Initial staging · CPT 78815
- Unfavorable-intermediate risk or higher
- PSA and Gleason documented
- No prior PSMA PET for staging
- Conventional imaging report attached
- Anthem RAD.00072Revised
- Cigna MM 0553Annual review
- Aetna CPB 0964Codes added
Coverage matrix
Every payer in one view, with the policy behind each cell.
Determination
Which criteria the chart already meets, and what to attach before you submit.
Change feed
When a policy in the matrix is revised, the cell updates and the diff is one click away.
How it works
From a thousand payers to one answer.
- Step 1 · 1,200+ payers · always current
Track every payer
Policies from 1,200+ payers, programs, and delegated vendors are monitored on a schedule tuned to how often each one actually changes. New and revised policies enter the library the day they take effect.
- Step 2 · Codes · dates · criteria
Extract the criteria
Each policy is read into structured fields: policy number, effective and revision dates, states and lines of business, CPT, HCPCS, and ICD codes, indications, exclusions, and documentation requirements. Low-confidence reads go to a human, never into the catalog.
- Step 3 · One therapy · every payer
Build the coverage matrix
Policies are matched to the same therapy across payers, so one query shows covered, covered with criteria, or not covered for every plan, with the governing policy behind each cell.
- Step 4 · Diff · summary · alert
Alert on change
Every new version produces a redline diff and a plain-language summary scored for materiality. Changes that matter reach your saved searches and inbox. Minor edits stay attached to the policy without the noise.
Capabilities
Everything a policy team does by hand, done for them.
Policy library
Medical, prior authorization, payment, and pharmacy policies, provider manuals, fee schedules, forms, and bulletins from commercial, Medicare Advantage, and Medicaid plans.
Coverage matrix
Any therapy, procedure, or code across every payer you track, with the governing policy and its criteria one click away.
Change monitoring
Automated detection of revisions with a redline diff, a summarized change, and a materiality score so your team reads only what matters.
Point-in-time history
Every version is kept, never overwritten. Ask what was in effect on any date of service and get the exact policy.
Rapid determination
The coverage answer for a patient, which criteria the record already meets, and what to attach before the request goes out.
API access
Policies, versions, diffs, coverage, and a change feed available programmatically for your own tools and workflows.
Who it is for
Built for everyone who has to know what the payer will say.
- Providers
Know the criteria before the request goes out.
Clinics, practices, and health systems use Prisym to submit against the payer's current policy instead of discovering it from a denial.
See how providers use Prisym - Revenue cycle
Preempt denials and prove what applied.
Authorization, billing, and denials teams get change alerts on the payers they bill and the exact policy version in effect on the date of service.
See how revenue cycle use Prisym - Life sciences
Track coverage for a therapy across the market.
Market access teams follow every payer's position on a product, competitors included, and hear the day a policy moves.
See how life sciences use Prisym - Payers
See your policies the way providers do.
Policy and network teams benchmark against peers, catch inconsistencies across lines of business, and confirm delegated vendors stay aligned.
See how payers use Prisym
Built to be trusted
The payer's policy is the authority. Prisym never edits it.
Append-only
No policy version is ever overwritten or deleted. Claims disputes depend on the policy in effect on a given date, so every one is kept.
Policy text preserved
The payer's own language is kept intact. Extracted metadata is a navigation layer with its confidence recorded, not a replacement.
Human review where it counts
Anything the automation is not confident about, from an unusual policy to an ambiguous match, goes to a review queue instead of the live catalog.
No patient data required
The library, matrix, and alerts work from payer policy alone. Determinations run on de-identified clinical facts you choose to provide.
Full audit trail
Every catalog change records what caused it: a scheduled run, a model, or a named reviewer, with the evidence attached.
Payer criteria, unaltered
Prisym shows the payer's stated criteria as written, with the exact before-and-after text whenever a policy changes.
Questions
What teams ask before they start.
Commercial, Medicare Advantage, Medicaid, and government programs across the United States, plus the delegated entities many plans rely on, such as Evicore, Carelon, Evolent, and Prime Therapeutics. Policy types include medical policies, prior authorization policies and lists, payment and reimbursement policies, pharmacy policies, provider manuals, fee schedules, forms, and bulletins. Plans that do not maintain a policy type are marked as a known gap rather than left blank.
Ready to see coverage in full spectrum?
Name a therapy. We will show you its coverage across every payer we track, and the last policy that changed.