The Same Case Gets Different Decisions
Same guidelines, different outcomes depending on who reviews. Inconsistent interpretation is both an operational and a fairness problem.
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The Real Problems Inside Every UM Programme
UM goals are right. The execution — in most health plans — is broken. Each failure compounds into reviewer burnout, provider frustration, and inconsistent determinations.
Volume Is Growing and Reviewer Capacity Is Not
Volume grows every year, but clinical staff doesn't scale — leaving queues and turnaround times stretching each quarter.
Routine Cases Are Consuming Clinical Reviewer Time
Straightforward cases land in the same queue as complex ones — consuming clinical time without needing a clinician's judgment.
Overutilisation and Underutilisation Are Both Happening
Most UM programmes flag overutilisation but miss the opposite — members who should get care aren't. One direction misses half the problem.
The Audit Trail Is Thin and Documentation Is Inconsistent
When a determination is challenged, manual UM rarely has a clean record — reconstructing the criteria applied is slow and a compliance risk.
How the Platform Works — Across the Full UM Lifecycle
An intelligence layer, not a replacement for clinical judgment — every determination is grounded in the same evidence and the same criteria.
Cross-references each submission against your criteria, auto-approves routine cases, and routes complex ones with a structured summary for the reviewer.
Re-evaluates medical necessity via live EHR and ADT feeds — case managers see current status, predicted length of stay, and discharge readiness.
Flags mismatches, norm deviations, and overbilling across your claims portfolio — each case surfaces with the signals that triggered it, ready for audit.
Auto-assembles the full case record on appeal — determination history, criteria applied, documentation, and notes, with peer-to-peer scheduling built in.
Your criteria — MCG, InterQual, NCI, or proprietary — configured into the guideline library, auto-updated, and read against clinical narratives.
Flags procedure deviations and outlier provider patterns across your full member population, feeding care-gap alerts into care management programmes.
What Your UM Team Sees Every Day
Complete operational visibility across every stage of the UM lifecycle — prospective, concurrent, and retrospective — with the analytics your clinical leadership needs to manage capacity, quality, and performance in real time.
UM Operations Dashboard
Live view of the full UM queue — by case status, type, clinical urgency, and reviewer assignment. Auto-approved, pending, escalated, and info-pending cases in one place. Auto-determination rate, reviewer workload, and turnaround trends at a glance.
Determination Consistency & Criteria Performance
See where human reviewers diverge on similar clinical presentations and which criteria drive the highest variance. Identify which denials are overturned most on appeal — so you can update guidelines before inconsistency becomes a regulatory concern.
Utilisation Trend Analytics
Admission rates, length of stay, procedure utilisation by diagnosis, and care setting appropriateness — broken down by region, plan type, and provider. Overutilisation and underutilisation visible simultaneously, with care gap alerts feeding into care management programmes.
Who This Platform Is Built For
Built for the full UM ecosystem — national insurers, managed care organisations, TPAs, government schemes, and workers compensation plans.
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Health Insurance Companies
Health Insurance Companies
AI-powered UM handles routine volume automatically, ensures consistency at scale, and gives your clinical team the tools to manage complex cases faster — with population-level analytics to drive strategic improvement.
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Managed Care Organisations
Managed Care Organisations
Consistent, evidence-based determinations and the analytics to continuously improve them — driving criteria refinement that improves quality metrics, utilisation benchmarks, and appeals outcomes quarter over quarter.
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Third Party Administrators
Third Party Administrators
Scales with your client portfolio without growing reviewer headcount. Every determination is fully documented — so when a client requests a UM audit, the data is ready.
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Government Health Schemes
Government Health Schemes
Built to NHCX standards, ABHA integration, and IRDAI compliance. Consistent, documentable determinations at the volume and scrutiny Ayushman Bharat, CGHS, and state schemes demand — every case reviewed against the same criteria, regardless of region or provider.
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Workers Compensation and Disability Plans
Workers Compensation and Disability Plans
Evidence-based determinations reduce legal exposure from errors while improving clinical appropriateness. Every peer review and appeals exchange is logged with a complete audit trail.
Who This Platform Is Built For
Built for national insurers, MCOs, TPAs, and government health schemes. Hover a card to see how we work with each.
Health Insurance Companies
AI-powered UM clears routine volume automatically, freeing your team for complex cases.
Managed Care Organisations
Consistent, evidence-based determinations plus analytics to refine criteria and improve appeals outcomes.
Third Party Administrators
Scales with your client portfolio without more reviewers — every determination audit-ready in minutes.
Government Health Schemes
Built to NHCX, ABHA, and IRDAI standards — documentable determinations at Ayushman Bharat and CGHS volume.
Right Care. Right Patient. Right Time. At Any Volume.
Manual UM can't be consistent, fast, and fully documented at scale. AI-powered UM can — and plans investing now are building a compounding advantage in cost, quality, and provider relations.
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Frequently Asked Questions
[ 1 ]
How does the AI apply our specific UM criteria rather than industry defaults?
Your criteria — MCG, InterQual, proprietary guidelines, IRDAI, or scheme-specific rules — are configured into the platform's guideline library at implementation. When guidelines update, the change takes effect immediately across all reviews. No reviewer ever works from a superseded version.
[ 2 ]
What happens when the AI cannot make a confident determination?
Every case gets a confidence score. Below your threshold, it routes to a clinical reviewer with a complete summary, relevant criteria, and the factors that triggered escalation — never a blank intake form.
[ 3 ]
How does concurrent review work when clinical information is changing continuously?
The platform integrates with EHR feeds, ADT notifications, and clinical documentation systems to monitor active cases in real time. When documentation updates, it re-evaluates immediately and flags clinically significant changes. Case managers always see current status — not a first-review snapshot.
[ 4 ]
Is the system compliant with IRDAI regulations and Indian market requirements?
Yes. Built to IRDAI clinical review requirements, NHCX data standards, and ABHA-compatible records with full audit trails for regulatory review and grievance redressal. Ayushman Bharat and state scheme UM requirements are supported in implementation configuration.
[ 5 ]
How does the platform support peer-to-peer review between plan physicians and treating physicians?
Peer review requests are logged, assigned, scheduled, and documented within the platform. Every exchange creates a complete, auditable record of who participated, what was discussed, and what determination was reached.
[ 6 ]
How quickly do we see improvement in auto-determination rates and reviewer efficiency?
Most plans see meaningful auto-determination from the first week. Rates improve over 60–90 days as the AI calibrates to your population and case mix. Reviewer time savings are typically visible within the first month as routine volume shifts out of the human queue.
[ 7 ]
What makes this utilization management software different from a standalone utilization review tool?
Our utilization management software covers the full review lifecycle rather than one step in isolation. It handles prospective, concurrent, and retrospective review inside one platform, so a case never has to move between disconnected systems. The built in utilization management AI scores each case and routes only the ones that need clinical judgement to a reviewer. Every determination keeps a complete audit trail for regulatory review and grievance redressal.
[ 8 ]
Does the platform work as utilization review software for managed care organisations and TPAs?
Yes. The same utilization review software is used by health insurers, managed care organisations, TPAs, and government schemes. Your own clinical criteria, whether MCG, InterQual, proprietary guidelines, or scheme rules, are configured into the guideline library at implementation. As UM software healthcare teams rely on, it applies those criteria consistently across every case and keeps audit trails for each determination. This gives multiple lines of business one consistent review process instead of separate manual workflows.
[ 9 ]
How does the medical necessity review software keep determinations explainable and auditable?
Every determination produced by the medical necessity review software cites the specific criteria and the clinical factors behind the decision, so it is never a black box. The utilization management AI attaches a confidence score and, when that score is below your threshold, routes the case to a clinical reviewer with a complete summary. Each case in the utilization management software retains a full audit trail of who reviewed it and what guideline version applied. That record supports regulatory review, appeals, and peer to peer discussion without rebuilding the history by hand.
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