Illustrative targets from eligibility automation, gold-carding, policy-driven auto-approval and straight-through intake.
AI reads. Rules decide. The UM, Case Management and Appeals platform for health plans — AI reads every document, and a deterministic rules engine makes the decision, citing the exact criterion, every time. FHIR-based CMS-0057 prior authorization, intake from every channel, and a system that cannot deny on its own.
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, your codified criteria, gold-card bypass, nurse & MD review.
Evaluates each request against your codified policy and auto-approves only when every required criterion is met — citing each one. 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, standards-based (CMS-10003) and audit-logged.
Not a slideshow of screens — the five things AI-UM Care commits to on every single case.
Follow one request all the way through: it arrives on any channel, lands in a single queue, is decided by a deterministic engine against policy your own team codified — and the result pushes straight to your downstream systems. No path through this diagram ends in an automated denial.
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.
Deployed single-tenant in your own cloud tenant, so PHI stays in your environment. Security and compliance certifications are on our published roadmap — we share our current security posture and SOC 2 / HITRUST timeline under NDA.
The complete UM suite is the base product — AI decisioning and policy digitization included, not upsold. Add modules as you expand. Every deployment runs single-tenant in your own cloud tenant.
The complete UM suite — priced per member
Extend across the enterprise when you need it
For national payers & complex estates
Book a personalized demo and watch your own policies auto-adjudicate.
Or email salesinfo@aiumcare.com