Overview

Automated validation for drug prescriptions, dosage limits, and clinical interactions.

Beta Availability

The Drug Adjudication API is currently in Beta. While functional, please anticipate limited medication coverage and potential breaking changes to the API specification.

Currently, medications must be submitted as structured objects. We are working on adding support for standard identifiers like NDC codes in upcoming releases.

The Drug Adjudication API serves as a sophisticated clinical safeguard for medication management. It analyzes prescribed medications in the context of patient demographics, diagnoses, and concurrent medical conditions and therapies to ensure safety, medical necessity, and adherence to dosing guidelines.

This API is particularly valuable for pharmacy benefit management (PBM) systems, as it streamlines real-time drug evaluations, reduces claim denials, and ensures accurate, compliant prescribing. By integrating this API, healthcare and PBM platforms can help prevent adverse drug events, promote formulary adherence, and boost the overall efficiency of medication management.

Use Cases

Pre-Prescription Checks

Validate prescriptions at the point of care to prevent errors before the patient leaves the clinic.

Pharmacy Benefit Management (PBM)

Automate the review of pharmacy claims for medical necessity and dosage compliance.

Clinical Decision Support

Alerts providers to potential dosage issues by evaluating the patient's individualized demographics and medical history.

Patient Safety Monitoring

Identifies potential contraindications based on the patient’s comorbidities, history, and drug–drug interaction risks.

Data Sources

We anchor our adjudication framework in FDA-approved medical standards and clinical guidelines.

FDA Standards

FDA-approved medical standards.

Clinical Guidelines

Clinical guidelines.

Violation Types

We return specific violation codes to help you understand why a medication was flagged.

1. Medical Necessity (DLE)

DLE1

Diagnosis Mismatch

Ensures the medication is clinically indicated for the patient's diagnosed conditions.

Description: Diagnoses do not necessitate the use of the medication.
Example: Prescribing Metformin (diabetes) for a patient with only Hypertension diagnosis.

{
  "rule": "DLE1",
  "level": "critical",
  "description": "Diagnoses do not necessitate the use of the medication",
  "medications": ["Metformin"]
}

DLE2

Dosage Necessity

Checks if the specific dosage prescribed/claimed is allowed given the diagnosis and the demographics

Description: Diagnoses do not necessitate the use of the medication in the prescribed dosage.

{
  "rule": "DLE2",
  "level": "warning",
  "description": "Diagnoses do not necessitate the use of the medication in the prescribed dosage",
  "medications": ["Ibuprofen"]
}

2. Contraindications (DCV)

DCV1

Comorbidities Contraindication

Identifies if a drug is medically contraindicated to be given, considering the patient's other medical conditions.

Description: Drug contraindicated with comorbid condition.
Example: Prescribing Beta-blockers to a patient with Asthma.

{
  "rule": "DCV1",
  "level": "critical",
  "description": "Drug contraindicated with comorbid condition",
  "medications": ["Propranolol"]
}

3. Drug Interactions (DDV)

DDV1

Drug-Drug Interaction

Detects possible deleterious drug–drug interactions arising from co-administration of multiple therapeutic agents.

Description: Potential drug–drug interaction detected between prescribed medications.

{
  "rule": "DDV1",
  "level": "critical",
  "description": "Potential drug–drug interaction detected between prescribed medications.",
  "medications": ["Warfarin", "Aspirin"]
}

4. Dosage Safety (DOV)

DOV1

Dosage Limit Exceeded

Flags dosages that exceed recommended maximums for safety, considering age and weight.

Description: Prescribed dosage exceeds the recommended maximum limit.

{
  "rule": "DOV1",
  "level": "warning",
  "description": "Prescribed dosage exceeds the recommended maximum limit",
  "medications": ["Acetaminophen"]
}

Criticality & Workflows

Critical

Denial Risk: High

Fundamental errors that will cause claim rejection. These require clinical review.

Warning

Compliance Alert

Potential issues that may be valid with proper documentation or modifiers.

Info

Informational

Suggestions and informational alerts that do not affect claim validity but may improve accuracy.

Endpoint

POST /adjudicate

Data Requirements

To ensure accurate adjudication, provide as much patient context as possible:

Medications: The list of drugs to evaluate, defined as structured objects (support for NDC codes is planned).
Diagnoses: Required to validate medical necessity (DLE & DCV rules).
Age, Sex, Weight: Crucial for calculating safe dosages.