Intelligence reads. Rules decide. A deterministic prior-auth engine that plugs into the UM ecosystem you already run — so you meet the mandate in weeks, not a rip-and-replace.
The Accuracy with Intelligence Engine sits between your intake and your system of record. It provides the compliant front door, auto-adjudicates against the policies your team codified, and writes the result straight back into the UM system you already run.
FHIR CRD/DTR/PAS · provider portal · fax OCR · X12 278 · delegated-MCO files — every channel, one front door.
Intelligence scans; rules decide against your policies and cite every criterion. Auto-approves the clean cases, routes the rest to your clinicians. Never denies on its own.
Writes the authorization or opens the case in Jiva, HealthEdge GuidingCare, MedHOK, Evolent or your homegrown UM — via that system's own APIs.
Providers submit via the FHIR prior-auth APIs, your portal, fax, or X12 278 — the engine normalizes it all into one canonical case.
Intelligence extracts the clinical facts; the deterministic engine evaluates them against your codified criteria and cites each one. Clean cases auto-approve; anything adverse routes to a licensed clinician — it never denies on its own.
Pluggable connectors map the outcome — authorization, dates, criteria cited, or a pended case/task — into Jiva, HealthEdge GuidingCare, MedHOK, Evolent or your homegrown system through its own APIs. Idempotent, reconciled, fully audited.
Decision timeliness and the CMS-0057 prior-authorization metrics are captured on every transaction — audit-ready by design.
Most established UM systems weren't built for the Interoperability & Prior Authorization Final Rule. The engine supplies the FHIR APIs, decision timeliness and reporting the mandate expects — on top of the system you already run.
✓ Compliant in weeks — no rip-and-replace of your system of record.
✓ Your reviewers keep working in the tool they already use.
✓ Straight-through auto-adjudication on the clean cases.
✓ Clinician-in-the-loop — the engine never auto-denies.
✓ Single-tenant in your cloud — PHI never leaves your tenant.
A pluggable connector framework maps the engine's canonical decision into your system of record — over whatever transport that system speaks.
Jiva, HealthEdge GuidingCare, MedHOK, Evolent or a homegrown platform — a connector per system maps auths, statuses, criteria cited, documents and notes.
REST/JSON, SOAP, X12 278/275, HL7v2, FHIR or SFTP batch — with RPA as a fallback where a system has no open write API.
Canonical-to-vendor field mapping and code crosswalks are configured, not coded — the same mapping tooling used for MCO intake.
Idempotency keys, downstream IDs stored back on the record, retries with a dead-letter queue, and status reconciliation — nothing is lost.
A thin, deterministic layer between your intake and your system of record — every part of it running inside your own cloud tenant.
The engine is the system of decision; your incumbent stays the system of record. Turn on the full workbench later and the same deployment becomes the system of record too.
Because it's the same deployable, the engine is the on-ramp to the full AI-UM Care suite. Meet the mandate today; switch on the workbench, letters, appeals and analytics when you're ready to modernize your system of record — with your data and decisions already in place.
Book a personalized demo — we'll show intake, deterministic decisioning and a write-back into a sample UM system.
Or email salesinfo@aiumcare.com
The prior-authorization mandate, the deadlines, and how to comply without replacing your UM system.
CMS-0057-F is the CMS Interoperability and Prior Authorization Final Rule, finalized in January 2024. It requires impacted health plans to streamline prior authorization with FHIR-based APIs, faster decision timeframes, specific denial reasons, and public reporting of prior authorization metrics.
Medicare Advantage organizations, state Medicaid and CHIP fee-for-service and managed care programs, and Qualified Health Plan issuers on the Federally-Facilitated Exchanges.
The FHIR Prior Authorization API, along with the Patient Access, Provider Access and Payer-to-Payer APIs, must be in place by January 1, 2027. Faster prior authorization decision timeframes took effect on January 1, 2026.
72 hours for expedited (urgent) requests and 7 calendar days for standard requests, effective January 2026.
Four: Patient Access, Provider Access, Payer-to-Payer, and the Prior Authorization API. The Prior Authorization API uses the HL7 Da Vinci CRD, DTR and PAS implementation guides.
The AI-UM Care UM Engine plugs in front of your existing utilization management system as a CMS-0057 front door, providing the FHIR CRD/DTR/PAS APIs, deterministic auto-adjudication, and writing decisions back into Jiva, HealthEdge GuidingCare, MedHOK, Evolent or a homegrown system through their own APIs.
Payers must publicly report metrics each year, including approval and denial rates and average decision turnaround time, and every denial must include a specific reason.
Yes. AI-UM Care deploys single-tenant inside your own cloud tenant (BYOC), so PHI, documents and decisions never leave your environment.