{ "$schema": "http://json-schema.org/draft-07/schema#", "title": "TwinFyRx suspecting_rule.rule_logic", "description": "One JSON Schema branch per rule_category value. The rule_executor.py in the SDK translates any valid rule_logic into executable SQL or evaluates it in-memory. Codes ending in '*' are ICD-10 prefix patterns (LIKE match); ATC codes are prefix-matched against the ndc_atc crosswalk.", "oneOf": [ { "$comment": "rule_category = prescriber_specialty, operator = switch", "title": "prescriber_specialty — specialty-to-diagnosis routing", "description": "Routes a claim toward different suspected ICD-10 targets based on the prescribing specialty. Each branch maps one or more specialty values to a list of candidate diagnoses. The executor renders a UNION ALL query, one branch per set of specialties.", "type": "object", "required": ["operator", "field", "branches"], "additionalProperties": false, "properties": { "operator": { "type": "string", "const": "switch" }, "field": { "type": "string", "const": "prescriber_specialty" }, "branches": { "type": "array", "minItems": 1, "items": { "type": "object", "required": ["values", "target_icd10"], "properties": { "values": { "type": "array", "items": { "type": "string" }, "description": "Prescriber specialty strings (exact match, case-sensitive)." }, "target_icd10": { "type": "array", "items": { "type": "string" }, "description": "Suspected ICD-10 codes for this specialty group. Use the first element as the primary target." }, "confidence": { "type": "number", "minimum": 0, "maximum": 1, "description": "Per-branch confidence override. Falls back to the rule-level confidence field if absent." } } } } }, "examples": [ { "operator": "switch", "field": "prescriber_specialty", "branches": [ { "values": ["Rheumatology", "Immunology"], "target_icd10": ["M05.9"], "confidence": 0.85 }, { "values": ["Dermatology"], "target_icd10": ["L40.50"], "confidence": 0.72 } ] } ] }, { "$comment": "rule_category = patient_age", "title": "patient_age — age-based prior or exclusion", "description": "A single field comparison or an AND composite restricting by patient age at fill date. The field patient_age_years resolves to members.age_at_fill in the claims schema. Supports BETWEEN, >=, <=, >, <.", "type": "object", "required": ["field", "operator", "value"], "additionalProperties": false, "properties": { "field": { "type": "string", "const": "patient_age_years" }, "operator": { "type": "string", "enum": ["=", "!=", ">=", "<=", ">", "<", "BETWEEN"] }, "value": { "oneOf": [ { "type": "number", "description": "Single age threshold." }, { "type": "array", "items": { "type": "number" }, "minItems": 2, "maxItems": 2, "description": "For BETWEEN: [lower, upper] inclusive." } ] } }, "examples": [ { "field": "patient_age_years", "operator": "BETWEEN", "value": [18, 65] }, { "field": "patient_age_years", "operator": ">=", "value": 50 } ] }, { "$comment": "rule_category = patient_gender", "title": "patient_gender — gender-based prior", "description": "Restricts suspects to a specific patient gender. Usually compounded with age (see compound category).", "type": "object", "required": ["field", "operator", "value"], "additionalProperties": false, "properties": { "field": { "type": "string", "const": "patient_gender" }, "operator": { "type": "string", "enum": ["=", "!="] }, "value": { "type": "string", "enum": ["M", "F"], "description": "'M' or 'F'." } }, "examples": [ { "field": "patient_gender", "operator": "=", "value": "F" } ] }, { "$comment": "rule_category = concurrent_rx", "title": "concurrent_rx — co-prescribing signal", "description": "Fires when the member has (or does not have) concurrent fills in a given ATC therapeutic class within a lookback window. ATC codes are prefix-matched against the ndc_atc crosswalk (e.g. C07A matches all beta-blockers). match_type 'none' inverts the predicate (NOT EXISTS).", "type": "object", "required": ["operator", "atc_classes"], "additionalProperties": false, "properties": { "operator": { "type": "string", "const": "concurrent_rx" }, "atc_classes": { "type": "array", "items": { "type": "string" }, "minItems": 1, "description": "ATC level-3 or level-4 prefix codes (e.g. 'C07A', 'M05BA')." }, "lookback_days":{ "type": "integer", "minimum": 1, "default": 90, "description": "Days before the index Rx fill to search for concurrent fills." }, "match_type": { "type": "string", "enum": ["any", "all", "none"], "default": "any", "description": "'any' = at least one ATC class present; 'all' = all classes present; 'none' = none present (exclusion rule)." } }, "examples": [ { "operator": "concurrent_rx", "atc_classes": ["C07A", "C09A"], "lookback_days": 90, "match_type": "any" }, { "operator": "concurrent_rx", "atc_classes": ["A10B"], "lookback_days": 180, "match_type": "none" } ] }, { "$comment": "rule_category = medical_claims_history", "title": "medical_claims_history — prior diagnosis or procedure", "description": "Fires when the member has a matching diagnosis code or procedure code in the medical claims lookback window. ICD-10 codes ending in '*' are treated as prefix patterns (e.g. 'M32.*' matches all Systemic Lupus codes).", "type": "object", "required": ["operator", "match"], "additionalProperties": false, "properties": { "operator": { "type": "string", "const": "claims_history" }, "match": { "type": "object", "required": ["type", "codes"], "properties": { "type": { "type": "string", "enum": ["diagnosis_code", "procedure_code", "diagnosis_or_procedure"], "description": "What to search for in medical claims." }, "codes": { "type": "array", "items": { "type": "string" }, "minItems": 1, "description": "ICD-10-CM codes (optionally ending in '*' for prefix match) or CPT procedure codes." } } }, "lookback_days": { "type": "integer", "minimum": 1, "default": 365, "description": "Days before the index Rx fill to search for prior medical claims." } }, "examples": [ { "operator": "claims_history", "match": { "type": "diagnosis_code", "codes": ["M05.9", "M32.*"] }, "lookback_days": 365 }, { "operator": "claims_history", "match": { "type": "procedure_code", "codes": ["96413", "96415"] }, "lookback_days": 180 } ] }, { "$comment": "rule_category = compound", "title": "compound — multi-signal composite", "description": "Combines two or more conditions from different signal sources using AND / OR logic. Each condition in the array may itself be a field comparison, concurrent_rx, or claims_history node. Nesting is supported for complex compound rules.", "type": "object", "required": ["operator", "conditions"], "additionalProperties": false, "properties": { "operator": { "type": "string", "enum": ["AND", "OR"] }, "conditions": { "type": "array", "minItems": 2, "items": { "type": "object", "description": "A field comparison, concurrent_rx node, or claims_history node. May be nested AND/OR." } } }, "examples": [ { "operator": "AND", "conditions": [ { "field": "patient_gender", "operator": "=", "value": "F" }, { "field": "patient_age_years", "operator": ">=", "value": 55 } ] }, { "operator": "AND", "conditions": [ { "operator": "concurrent_rx", "atc_classes": ["L04A"], "lookback_days": 90, "match_type": "any" }, { "operator": "claims_history", "match": { "type": "diagnosis_code", "codes": ["M45.*"] }, "lookback_days": 365 } ] } ] }, { "$comment": "rule_category = single_indication", "title": "single_indication — drug-wide rule with no conditions", "description": "Used when a drug maps to exactly one clinical indication with very high confidence (is_single_indication_drug = true). The rule logic is empty — all fills of this drug are suspected for the associated ICD-10 code regardless of claims context.", "type": "object", "maxProperties": 0, "examples": [{}] } ] }