The Same Case Gets Different Decisions
Same guidelines, different outcomes — depending on who reviews the case. 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. Clinical staff doesn't scale with it — leaving queues behind and turnaround times stretching each quarter.
Routine Cases Are Consuming Clinical Reviewer Time
Straightforward cases still land in the same queue as complex ones — consuming the same clinical time without needing a clinician's judgment.
Overutilisation and Underutilisation Are Both Happening
Most UM programmes flag unnecessary procedures — but miss the equal and opposite problem: members who should be receiving care aren't getting it. Looking in only one direction misses half the failure.
The Audit Trail Is Thin and Documentation Is Inconsistent
When a determination is challenged by a provider, member, or regulator, manual UM rarely has a clean record. Reconstructing what criteria were applied and why is slow, incomplete, and a compliance and legal risk.
How the Platform Works — Across the Full UM Lifecycle
An intelligence layer, not a replacement for clinical judgment. Every determination, automated or human-reviewed, is grounded in the same evidence and applied against the same criteria.
Cross-references each submission against your criteria, auto-generates clear approvals for routine cases, and routes complex cases with a structured summary ready for the clinical reviewer. No blank intake forms.
Re-evaluates medical necessity as documentation updates via EHR feeds and ADT notifications. Case managers see live status, predicted length of stay, and discharge readiness — not a first-review snapshot.
Flags mismatches, norm deviations, and overbilling patterns across your claims portfolio. Every flagged case surfaces with the details and signals that triggered it — ready for recovery or audit.
Auto-assembles the full case record on appeal — determination history, criteria applied, clinical documentation, and reviewer notes. Peer-to-peer review scheduling and outcome recording built in.
Your criteria — MCG, InterQual, NCI, or proprietary guidelines — configured into the platform's guideline library and auto-updated as standards change. Reads clinical narratives, not just structured fields.
Flags procedure deviations and outlier provider patterns across your full member population. Care gap alerts feed directly into care management programmes, driving strategic improvement quarter over quarter.
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 the full UM ecosystem — national insurers, managed care organisations, TPAs, and government schemes. Hover a card to see how we work with each.
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 quarter over quarter.
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. Every determination grounded in the same criteria, every time.
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 or a regulator asks for case records, the data is ready and assembled in minutes.
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.
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.
Book a UM AI Demo
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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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