Intelligence reads. Rules decide. The UM, Case Management and Appeals platform for health plans.
Meet the CMS-0057 mandate in weeks — without a rip-and-replace. AI-UM Care's deterministic engine sits between your intake and the UM system you already run, auto-adjudicates against the policies your team codified, and writes the result straight back into Jiva, HealthEdge GuidingCare, MedHOK, Evolent and more — through their own APIs.
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.
A compliant FHIR prior-auth front door and straight-through auto-adjudication, without changing how your reviewers work.
The same deployable, configured to your endpoints. Pluggable connectors map each decision into your UM system of record.
Single-tenant in your own environment. PHI, decisions and audit records never leave your tenant.
Start with the engine today; switch on the full workbench, letters and appeals when you're ready to modernize.
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 platform 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.
Codify your policy, then run it on every request: the Policy Codification Engine and the UM Engine go hand in hand. Start with the pair, grow into the full suite — every deployment single-tenant in your own cloud tenant, priced to your membership.
UM Engine + Policy Codification Engine — priced per member
The complete suite — priced per member
Just one engine, if that's all you need
Enterprise support, premium SLAs and custom integrations are available for national payers & complex estates — contact sales.
Book a personalized demo and watch your own policies auto-adjudicate.
Or email salesinfo@aiumcare.com