medical-invoice-medical-audit

To audit clinical pertinence, evaluate billed services against the 29 PERT-CLIN rules using GPC guidance. Map CIE-10 codes to correct criteria and generate a medical_checklist_output.json with an APTA or NO_APTA verdict and evidence citations.

The PERT-CLIN rule checklist is a 29-point evaluation framework used to verify that billed medical services align with clinical guidelines. It checks documentation adequacy and clinical justification to reduce inappropriate charges and payer disputes.

Map CIE-10 codes to clinical criteria by applying GPC guidance when the GUIAS_CLINICAS_PATH is available. This ensures the billed services match guideline-consistent criteria before producing the final APTA or NO_APTA verdict.

Yes, this audit process integrates with MinSalud references to ensure guideline-consistent decisions. It evaluates invoice evidence against applicable GPC criteria to determine if billed items are clinically justified for MinSalud compliance.

The medical_checklist_output.json contains detailed results for 29 PERT-CLIN rules, including evidence citations, confidence scores, and a final cierre section that provides the final APTA or NO_APTA verdict for the audited invoice.

Clinical pertinence auditing requires evidence citations to verify that billed medical services are adequately documented and clinically justified. This structured evidence supports the final APTA or NO_APTA verdict and reduces payer disputes.