Intelligence reads. Rules decide. The UM, Case Management and Appeals platform for health plans.
Everything in AI-UM Care runs on the same two engines you can also license on their own: the Accuracy with Intelligence Engine decides against your codified policy and never denies on its own, and the Policy Codification Engine turns your CMS and plan policies into the executable logic it runs.
Omnichannel intake (FHIR CRD/DTR/PAS, provider portal, fax OCR, X12 278, MCO files), deterministic auto-adjudication that cites every criterion, plus eligibility, benefits & cost-share — the decisioning core of the platform.
Imports CMS NCD/LCD and your plan policies and turns them into versioned, testable, executable CQL — the machine-readable criteria every decision cites.
Already run a UM system? The engines also deploy standalone as a CMS-0057 gateway that plugs into Jiva, HealthEdge GuidingCare, MedHOK or Evolent — see the UM Engine.
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