The agentic UM, Case Management and Appeals platform for health plans — FHIR-based CMS-0057 prior authorization, automated intake from every channel, and clinical decisioning that slashes turnaround time and admin cost.
A unified, FHIR-native suite across the full UM / CM / A&G lifecycle — configurable to your plans, policies and lines of business.
CRD/DTR/PAS intake, eligibility & benefits, MCG/InterQual criteria, gold-card auto-approval, nurse & MD review.
Scores each request against digitized policy and auto-approves the clear cases. Never auto-denies — adverse calls stay with a clinician.
Turns CMS NCD/LCD and plan policies into executable CQL. Import, version, publish, test.
Portal, fax OCR, EMR (FHIR) and delegated-MCO files — auto-parsed via configurable mappings, straight-through into UM.
Real-time PA with live eligibility, code & ICD lookups, criteria prompts, documents, status, secure messaging, appeals.
Stratification, care plans, assessments and HCBS waiver workflows — authorization through coordination.
Full A&G lifecycle, SLA tracking, overturn/uphold analytics, determination letters, IRE forwarding.
No-code stage pipelines with WHEN/IF/THEN rules. Onboard new review types without engineering.
Operational, compliance & KPI dashboards — TAT, denial & appeal rates, LOS, PDC/GSR, audit coverage, export.
Smart routing across the UM team — auto-assign cases to nurses, Medical Directors and pharmacists by skill, license, line of business and SLA-breach risk.
Medication prior auth with formulary, step-therapy and DUR safety checks. ePA (NCPDP SCRIPT) and FHIR PAS intake; pharmacist review and copilot.
Auth-to-claim matching and retrospective review with X12 278/835 interoperability — keeping authorizations and payment in lockstep.
Automated member & provider correspondence — approval notices and IDN denials (CMS-10003) with appeal rights. Templated, compliant and audit-logged.
Real workflows from the AI-UM Care application — built for reviewers, providers and administrators.
One screen from intake to determination — the rules engine shows exactly why each case was approved, pended or routed, with full member, provider and clinical context.
Providers check requirement, coverage and criteria in real time, attach documentation, then submit straight into your UM queue — with live status, secure messaging and appeals.
Out-of-the-box dashboards for operations, compliance and KPIs — with gauges, donuts and trend lines, drillable per module and exportable for auditors.
Configure UM workflows as no-code stage pipelines with WHEN/IF/THEN rules — and onboard delegated MCO feeds with field-mapping templates that auto-load straight through.
Portal, fax, EMR (FHIR) or MCO files → one normalized record.
Eligibility, benefits & PA list resolve; engine scores vs policy.
Clear cases auto-approve; rest route to nurse, MD, P2P. Never auto-deny.
278/PAS, letters & provider alerts fire; every action logged.
Watch the actual product — navigate the Workbench, see an AI auto-approval, the provider portal, no-code workflows and live analytics. Plays right here.
Tip: screen-record this tour to export an MP4 — or place a filmed video at assets/explainer.mp4 to use it instead.
Illustrative targets from automating eligibility, gold-carding, policy-driven auto-approval and straight-through intake.
Engineered around the Interoperability & Prior Authorization Final Rule and the HL7 Da Vinci guides — so you meet the mandate and the timeline.
✓ Clinician-in-the-loop — the AI never auto-denies.
✓ Explainable, policy-cited, logged decisions.
✓ Configurable per LOB, policy & workflow — no code.
✓ Straight-through intake from providers & MCOs.
✓ Deploys in your cloud or ours; integrates with your core admin system.
Modular and transparent. Start with prior auth, expand across the suite.
Regional & startup plans
Mid-size health plans
National payers
Book a personalized demo and watch your own policies auto-adjudicate.
Or email sales@aiumcare.com