The Clinical Policy Library
Rubrica is the sourced clinical policy library — every covered procedure, every commercial and government payor, every state — with the criterion-level decision logic and denial-risk scoring that turn coverage rules into auditable answers. Built to scale across every clinical specialty; deepest today in interventional spine, pain management, orthopedics, and spine surgery.
Latest from the digest
Oscar Health's CG047 v9 raised the RFA diagnostic-block relief threshold from ≥50% to ≥80% — a 30-percentage-point shift that affects every cervical and lumbar RFA prior auth submitted to Oscar. Also covered this month: TRICARE adds CPT 64628 (basivertebral nerve ablation), UHC Community Plan expands vertebroplasty coverage, and what to watch for in the CMS Q3 quarterly file.
The platform
For any state, payor, and CPT, Rubrica pulls the governing policy — LCDs for Medicare (auto-routed by MAC), CPBs and medical policies for commercial plans — and renders the required criteria as a plain checklist.
Enter what's documented — MRI date, conservative-care weeks, prior diagnostic blocks, ICD-10. Rubrica marks which criteria are met, missing, or not documented — with the failing criterion flagged in rubric red.
Every decision carries the policy number, effective date, last-reviewed date, and a link to the source document. Every output is printable as a clinic-ready PDF. Outcomes tracking closes the loop.
ii. Coverage Matrix
For any procedure, see each payor's disposition in your jurisdiction in a single view — useful for sequencing submissions, patient counseling, and identifying plans where a gap analysis is worth running.
| Payor | Disposition | Policy | Effective | Last reviewed |
|---|---|---|---|---|
| Medicare (FCSO / J-N) | Likely clears | L33906 | 10 / 2024 | 3 weeks |
| Aetna Commercial | Gap — 1 criterion | CPB 0016 | 02 / 2025 | 2 weeks |
| UnitedHealthcare Comm. | Likely clears | 2024T0623K | 11 / 2024 | 5 weeks |
| Cigna | Likely denies | 0556 | 01 / 2025 | 4 weeks |
| Florida Blue (BCBS-FL) | Verify with payor | 09-J0000-46 | 09 / 2024 | 11 weeks |
| Humana Medicare Adv. | Follows LCD | — | — | — |
Sample data shown. Coverage matrix reflects each payor's published policy of record.
iii. Built For
Rubrica is the agreement layer between the people who order procedures and the plans that cover them. Each stakeholder consumes the same sourced rule library — through a workflow that fits their job.
Eliminate hours of policy-PDF hunting. Run a check before scheduling. Cut denials at the order step — not in appeals.
Standardize coverage logic across sites and physicians. Reduce schedule churn, cancellations, and write-offs — at scale.
Specialty-deep clinical adjudication that integrates with existing UM workflows. Auditable, sourced, and aligned to your published medical policy.
Real-time visibility into coverage trajectory across payors and states for newly launched and emerging-tech procedures.
iv. Methodology
Every decision Rubrica returns is tied to a single policy document of record — with policy number, effective date, last-reviewed date, and a link to the original source. No black-box answers. Ever.
Three sources: Medicare LCDs and NCDs routed by MAC jurisdiction, commercial payor clinical policies, and curated coverage matrices contributed by member clinics.
Each rule is a single versioned JSON record. Source title, policy number, effective date, last-reviewed date, and applicable jurisdictions are first-class fields — not metadata.
Every rule older than 12 months is automatically flagged for re-review. First-pass stubs are tagged "Verify with payor" until reconciled against full policy text.
Corrections propagate to the entire system on the next deploy. Every prior decision is preserved in the audit log with the rule version that produced it.
Payor policy is a rubric. Rubrica renders it.
v. Governance
Rubrica is decision support, not a coverage determination. Patient health information is not stored. Compliance posture and architectural controls are public — because the people who buy enterprise software for healthcare deserve straight answers.
We work with interventional pain practices, multi-site ASC operators, and health plans actively modernizing their utilization management. A demo takes 30 minutes.
Answer as many fields as you can. More context sharpens the decision.
No PHI is stored. Use initials + DOB month only (e.g. KM / Jan — lumbar ESI Medicare). Cases live in this browser's local storage.
Self-funded ERISA plans are governed by the employer's plan document, not the carrier's medical policy. Coverage rules below may not apply. Always verify against the SPD.
Run your first policy check.
For any procedure, see each payor's disposition in your state side-by-side. Useful for choosing which payor to submit first, for patient counseling, and for identifying plans where a gap analysis is worth running.
Pick a state and search for a procedure.
Health view of Rubrica's policy coverage. Per-subspecialty stats, payor-class breakdown, and the oldest entries that need re-review.
Cells are policy counts. Empty/dim cells highlight gaps.
Empirical backfill priorities — most-requested combinations that returned no policy match. Recorded locally; no PHI sent to any server.
Each row shows the oldest last_reviewed_date across that payor's policies. Color reflects staleness vs. the v3 §11 SLA targets (≤30d green, ≤90d amber, >90d red).
Showing the 20 entries with the most distant last_reviewed_date.
Stub records imported from a payer-guidelines reference that haven't been reconciled against full payor text.
Capture and track patient-reported outcomes (PROMs). Instruments are filtered by your active subspecialty. No PHI is stored — use a de-identified label like initials + month.
Pick an instrument, score it with the patient.
Your most recent PROMs in this subspecialty.
Sign in to see saved submissions.
About
Rubrica is named for the Latin rubrica terra — "red earth" — the ochre pigment medieval scribes used to mark the rules, rubrics, and procedural headings in manuscripts and early legal texts. A rubric was literally the instruction written in red. Centuries later, the word came to mean any set of criteria by which a case is evaluated and graded.
That is exactly what this tool does. Payor policy is a rubric. Rubrica renders it.
For clinicians in any specialty, Rubrica is the clinical decision-support platform that replaces hours of policy-PDF hunting with a single, sourced answer — its policy database is curated per payor and per jurisdiction, handling the Medicare MAC variation that determines whether an ESI clears in Pennsylvania but not Texas, the BCBS / commercial / state-Medicaid variation that drives PA decisions, and the per-subspecialty depth that today goes furthest in interventional spine, pain management, orthopedics, and spine surgery.
No hedging. If the policy requires an MRI within twelve months, say so in those words.
Physician-native vocabulary. "Medial branch block" or "rotator cuff repair" — not "specialized injection." Respect the reader's training.
No "leveraging," no "synergize," no "best-in-class." Plain language that a practice manager and a board member can both parse.
Rubrica surfaces the requirement. Never "Rubrica guarantees approval." The tool is decision-support; the physician is accountable.
Rubrica was built by an interventional pain physician to solve the policy-PDF problem that still burns hours of clinic time for every practice in the country.
Trademark clearance is in progress. The name Rubrica has not yet completed USPTO search in Class 9 (software) or Class 42 (SaaS).
FAQ
No. Rubrica is decision-support — it reads the payor's published policy and tells you whether the criteria are likely met. The actual coverage determination is made by the payor after the submission. Always verify current policy and benefits before performing procedures.
Three sources: (1) Medicare LCDs and NCDs, routed by MAC jurisdiction, (2) commercial payor clinical policies (Aetna CPB, Cigna medical coverage, UHC medical policy, CareFirst, etc.), (3) curated payer-guidelines coverage matrices contributed by member clinics. Every rule in the database carries its source title, policy number, effective date, and last-reviewed date.
Manually, whenever a payor publishes a revision. The Library view flags any rule older than 12 months as "Review needed" and any first-pass stub — sourced from the coverage matrix alone without full policy text — as "Verify with payor."
Flag it. Every rule is a single JSON record sourced, versioned, and auditable. Corrections propagate to the whole system on the next deploy.
No. Rubrica runs entirely in your browser. No PHI is sent to any server. An audit log of decision queries (state, payor, CPT, likelihood — no identifiers) is kept in your browser's local storage, capped at the last 500 entries.
Medicare Advantage plans (UHC MA, Humana MA, Devoted, Wellcare) generally follow the traditional Medicare LCDs, but plan-specific variations exist. When you pick a Medicare Advantage payor, Rubrica shows the MA plan rule if one is on file; otherwise it falls back to the LCD.
2,960 CPTs are in the current build — coverage spans every clinical specialty, with the deepest depth today in interventional spine (ESI, facet/MBN, RFA, SCS, vertebral augmentation, intradiscal, peripheral nerve stim, MILD), pain management, orthopedics (joint replacement, sports/arthroscopy, hand/upper extremity, foot/ankle, trauma, viscosupplementation), and ortho spine (fusion, interbody, decompression, disc arthroplasty, instrumentation). Any specialty can be added on request.
Yes — Phase B. Per-clinic accounts with role-based access (clinician, billing, admin), contracted-rate overlays, and team audit log. Phase D adds iOS and Android.
Registered clinical and admin staff at partnered practices.
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Pin the values you want pre-filled every time you start a check. Leave any field blank to keep using your most-recent selection.
Replay the walkthrough of the policy-check workflow.
Get a weekly email summarizing payor coverage changes in the specialties you select. Sent to your account email.
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Your last 10 policy lookups, server-side. Click a row to re-load it in the policy check.
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Reports you've submitted to the Rubrica team. Status updates here when we resolve or close a ticket.
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Patient-reported outcomes you've logged. Filtered by your active subspecialty.
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Stored locally in this browser only — no PHI. Use initials + DOB month if you label them.
Rubrica stores no patient health information. Account data is limited to email, company, and user type. See FAQ for details.
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Rubrica now supports three subspecialties. Pick the one you'll use most often — you can switch contexts anytime from the topbar.
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