Utilization Management (UM)

Utilization Management (UM) supports end-to-end authorization processing—from intake to review and outcome—while automating routing, documentation, and approvals. It is designed to reduce your organization’s administrative burden and ensure better compliance with regulatory service level agreements (SLAs). UM optimizes intake, routing, clinical decision-making, correspondence, and compliance tracking across a variety of lines of business (LOBs), including Commercial, Medicare Advantage, and Medicaid.

Workflow Architecture

UM is built on the Medecision orchestration engine and follows a task-based design pattern.

Core Workflow Stages:

Request Intake (via Fax, Portal, or API)
Initial Evaluation (pre-checks, matching, and enrichment)
Decision Routing (rule-based vs manual vs medical director)
Medical Review / Peer-to-Peer
Correspondence Generation
Audit Logging and Closure

Workflows are defined in the Workflow Designer with version-controlled flows for different LOBs or intake sources.

Workflow Architecture

UM is built on the Medecision orchestration engine and follows a task-based design pattern.

Core Workflow Stages:

Request Intake (via Fax, Portal, or API)
Initial Evaluation (pre-checks, matching, and enrichment)
Decision Routing (rule-based vs manual vs medical director)
Medical Review / Peer-to-Peer
Correspondence Generation
Audit Logging & Closure

Workflows are defined in the Workflow Designer, with version-controlled flows for different LOBs or intake sources.

Intake Methods

Data Elements:

Member, provider, diagnosis, procedure codes
Plan-specific policy or guideline logic
Attachments and documentation

Routing & Decisions

Rules Engine:

Medical necessity determination based on:
CPT/HCPCS/ICD logic
Provider specialty
Historical utilization
Payer-specific benefit plans
Uses codified policies (e.g., MCG, InterQual, or custom)

Decision Rules:

Applied when:
Confidence threshold is met by AI model
Member history and coding aligns with configured rules
Auto-pend logic applied when documentation is missing or ambiguous

Medical Review & Peer Review

Queue Routing: Tasks are sent to MDs or delegated reviewers based on:
LOB and specialization
TAT status (e.g., urgent within 24hr)
Review Interface:
Configurable by LOB
Includes full clinical context and attachments
Peer-to-Peer Workflow:
Scheduler, phone fields, documentation of call outcome

Turnaround Time (TAT) Management

Each request is tagged with a TAT requirement.
SLA timers are configurable by:
Line of business
Type of request (urgent, standard, expedited)
Escalation logic includes:
Auto-promotion to supervisor queue
Email/SMS alerts
Status-driven auto-denial (optional)

Correspondence & Communications

Auto-generated Letters:
Approval, Denial, Request for More Info (RFI)
Templates configurable per client
Language & Format Support:
Multilingual support
Email, fax, portal messaging
Audit Trail:
Timestamps, user actions, and letter versions tracked

Compliance & Oversight

Audit Logs:
Every status change, assignment, and decision captured with timestamp and user ID
Delegation Oversight:
Distinct queues and logs for delegated partners
Summary reporting by entity and TAT category
Regulatory Alignment:
CMS-0057 Final Rule
State Medicaid rules
Medicare Advantage TAT monitoring