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INTAKE & DATA EXTRACTION
Every request is captured and normalized across channels
FHIR API, provider portal, EDI X12 278, and fax/OCR
NLP extracts clinical evidence from unstructured documents
Eligibility verified at intake, with immediate tracking
End-to-end utilization management, built for speed and compliance.
Agentic AI automates the full UM lifecycle, helping teams move faster while reserving clinical judgment for the cases that need it.
MEDICAL NECESSITY EVALUATION
Qualifying requests are
approved in real time.
All others are escalated, never auto-denied.
approved in real time.
All others are escalated, never auto-denied.
AI evaluates against plan-specific medical necessity criteria
Configurable by CPT code, line of business, and gold-card programs
Non-qualifying cases are routed with an AI-prepared clinical summary, helping reviewers move faster and members access care sooner.
MEDICAL NECESSITY EVALUATION
Qualifying requests are
approved in real time.
All others are escalated, never auto-denied.
approved in real time.
All others are escalated, never auto-denied.
AI evaluates against plan-specific medical necessity criteria
Configurable by CPT code, line of business, and gold-card programs
Non-qualifying cases are routed with an AI-prepared clinical summary, helping reviewers move faster and members access care sooner.
CLINICAL REVIEW WORKFLOW
Reviewers decide, not search.
Every case is pre-analyzed, deadline-tracked, and aligned to timely member care.
Every case is pre-analyzed, deadline-tracked, and aligned to timely member care.
AI-prepared summary, with evidence extracted and criteria gaps identified
Worklist prioritized by urgency and review timeline
Physician peer review is enforced for all adverse determinations
PROVIDER COMMUNICATION
Every decision reaches providers quickly and clearly.
Determination letters are auto-generated and sent via portal, email, or fax
Providers are notified quickly of approvals, denials, and additional information requests
Provider portal gives real-time status visibility, reducing inbound inquiry volume
Site-of-care guidance included with authorization responses
PROVIDER COMMUNICATION
Every decision reaches providers quickly and clearly.
Determination letters are auto-generated and sent via portal, email, or fax
Providers are notified quickly of approvals, denials, and additional information requests
Provider portal gives real-time status visibility, reducing inbound inquiry volume
Site-of-care guidance included with authorization responses
COMPLIANCE, ANALYTICS, AND REPORTING
Full visibility into performance, compliance, and turnaround readiness.
Real-time dashboard across approval rates, turnaround times, cost per PA, and denial trends
Automated turnaround tracking across all lines of business
Denial reasons documented with appeal rights included
PA metrics report available on demand
Surfaces avoidable utilization trends, including unnecessary imaging and procedures
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