Below is a list of commonly asked questions about Utilization Management (UM).

UM is a management process used by health plans to ensure members receive appropriate, medically necessary, cost-effective care

UM involves the evalution of necessity, appropriateness and efficiency of services, procedures, providers and facilities.

UM us a crucial component of medical cost management including identification of fraud, waste, abuse and overuse. UM can help identify patterns of underuse in support of member's receiving needed and life saving preventive care.

UM is conducted by health plans as an essential component of medical cost management. This includes cost control, quality assurance, regulatory compliance, resource allocation, early identification of clinical / support needs referrals.

What makes Medecision unique is Medecision™ is a HITRUST CSF®-certified, Software-as-a-Service (SaaS) solution, purpose-built for the healthcare industry. Designed as a true modern cloud-native platform on Google Cloud Platform (GCP), our cloud-first architecture spans all components of the platform, providing customers with a resilient, flexible, secure, and cost-effective solution that can scale in real-time to support growing and changing demands for data processing and critical healthcare applications.

• Medecision has achieved the HITRUST Risk-based, 2-year (r2) Certification for 2024. This certification signifies that Medecision's Information Security Program aligns its security controls and practices with the Health Information Trust Alliance (HITRUST) Common Security Framework (CSF). These security controls are independently evaluated, validated, and certified to ensure compliance with HITRUST, as well as applicable federal and state regulations governing the security of sensitive information, such as the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Health Insurance Portability and Accountability Act (HIPAA) Security Rule. For more detailed information, please refer to Exhibit Medecision AC2 HITRUST Certification Letter.

• NCQA Population Health Management (PHM) Prevalidation: We were among the first organizations in the nation to receive NCQA Population Health Management (PHM) Prevalidation Status for the Medecision solution in 2018. We have continued to keep our certification current as of today. The NCQA Prevalidation Status for Population Health Management identifies technology solutions with functionality and practices that assist health plans and other organizations in meeting population health management-related standards in NCQA accreditation programs.

Our platform leverages responsible AI capabilities, powered by Google Gemini and Vertex AI, to drive smarter, data-informed decision-making and optimize operational efficiency. This seamless AI integration enhances multiple key areas within our platform, empowering organizations to unlock deeper insights and take proactive action. The following represents a few examples of how we leverage AI in our platform:

• Guided Intake for UM Requests: Deliver smarter, guideline based prior authorization, auto- approvals and auto-decisioning based on payer policies, historical data, and AI assisted medical policy management. Solution supports EMR integration and and roadmap to support for CMS-0057.\ • Intelligent Auto-Routing: Enhance resource allocation and enable faster decisioning with automated routing and workload balancing

The system is designed to facilitate the prioritization of work and management of due dates through several integrated features:

• Due Date Calculation: This functionality gives customers the ability to define due date rules using a variety of member and request data elements which are used to calculate the due dates for each requested service. When a request is created/edited/extended with values matching conditions of due date rule, then due date will be auto calculated based on the units of the due date rule.\ • Queue Management: The system supports queue management tools such as dashboards and lists, enabling users to manage caseloads effectively. Pull queue functionality allows individual users to identify the most urgent requests based on the calculated due date so they can be worked first to ensure turnaround times are met.

These features collectively enhance the system's ability to prioritize work, manage due dates, and ensure timely and efficient responses to critical tasks.

Medecision Reporting offers a versatile real-time reporting framework to meet the diverse needs of all our customers. Our reporting features are designed to provide flexible reporting capabilities that minimize or eliminate the need for IT involvement. We provide three flexible reporting options, all options provide real-time data access, ensuring timely insights regardless of the chosen method.

Our Medecision platform is designed with a versatile, on-demand reporting framework. Medecision is also the only platform in the market to provide near real time reporting that gives customers an advantage over operational efficiencies.

Medecision Correspondence enables your teams to design, deploy, deliver, and manage personalized letters to members and providers. Integrated with industry leader Cincom, this module streamlines workflows by allowing letters to be sent directly from the platform, reducing clicks and saving time. This includes the ability to generate and manage required letters to members and providers, leveraging a third-party partner for outbound fax integration. The system allows for the customization of communication templates during the implementation stage, and customers receive training on how to customize these templates independently. Communications are automatically generated based on predefined triggers or events, and customers can control the conditions under which communications are triggered, offering flexibility in how and when messages are sent out. This automation reduces administrative burdens and significantly improves the efficiency of care teams and the overall member experience.

The system includes comprehensive controls for managing correspondence. All activities, including the creation and generation of correspondence, are captured as part of the application audit. This ensures that there is a timestamp for each action, providing a detailed log of when correspondence was created and generated. This feature supports transparency and accountability, allowing users to track and verify the timing and sequence of communication activities.

For Utilization Management (UM), the platform offers full integration to Millian Care Guidelines and Interqual Care Guidelines/ Change Healthcare. Customers will need to license directly with those organizations. The integration supports the below features:

• Data Exchange: This integration allows relevant member data, such as demographics, diagnoses, and procedures, to be shared between the systems.\ • Real-time Access: The integration enables real-time access to clinical decision support guidelines and criteria so users can access the criteria provided by the clinical decision support software to inform their decision-making process.\ • Criteria Application: The criteria would be used to evaluate the medical necessity, appropriateness, and compliance with guidelines for the proposed treatment or procedure.\ • Automation and Decision Support: The integration can enable automation of decision support within our solution and provide recommendations to the users regarding the next steps in the utilization management process.\ • Documentation and Audit Trail: The integration would support the seamless transfer of decision support recommendations, along with the associated member data, between the solution and the clinical decision support software. This ensures that the decision-making process, decisions made, and the rationale behind them are accurately documented and auditable.

Our quality tools include leveraging a NCQA certified solution that has a library of over 700 standardized measures to identify quality gaps, such as those related to STARS and HEDIS measures.

The platform can integrate with various data sources, such as electronic health records (EHRs), claims systems, and other clinical and administrative data repositories. Once aggregated, our platform automates the extraction of relevant data elements needed for HEDIS measure calculations.

For HEDIS reporting, customers can select from three primary reporting options, designed to meet diverse needs and customization levels:

• Library of Standard Reports: A comprehensive selection of pre-built reports, designed to fulfill HEDIS requirements and to serve as customizable templates for your specific reporting strategies\ • Customized Reports: Leverage our business intelligence tool to design and deliver customized reports that align perfectly with specific requirements\ • Direct Access: Have your own BI tool? Seamlessly connect it into the Medecision reporting database, so customers can directly query and generate reports, offering exceptional flexibility and autonomy.

UM requests can be generated in the system through various methods:

• Manual entry - users can manually create and assign requests as needed for additional clinical review.\ • Fax intake - users can attach the fax to an existing request or use the data from the fax to create a new request\ • Medecision Provider Portal - requests can be submitted via Medecision's provider authorization portal and auto-approved or be routed using Auto Workflow rules to be reviewed.

Additionally, Medecision supports API integration to other third-party provider portals through the developer portal, Medecision Access. This integration facilitates the intake process and ensures that clinical information needed to support authorization is efficiently delivered.

MD Reviews:\ Medecision UM is designed to provide flexibility in the physician review process, offering two distinct methods that optimize efficiency while ensuring compliance and high-quality clinical decision-making.

Peer Reviews:\ Medecision Utilization Management application streamlines the Peer-to-Peer (P2P) review process, providing a seamless, digital workflow for scheduling and documentation.

Effortless Scheduling\ • Either the Payer’s Medical Director or the Physician Provider of Care can request a Peer-to-Peer meeting directly within the platform.\ • The system offers a real-time scheduling interface, allowing both parties to select a mutually available time, eliminating manual coordination delays.\ Comprehensive Documentation - During the P2P discussion, the platform enables structured and flexible documentation:\ • Templated Questions & Answers: Standardized fields ensure consistency in case documentation.\ • Free-Text Notes: Allows for additional details, ensuring full clinical context is captured.\ • Service Outcome Review: The platform associates documentation directly with the service under review, maintaining a clear audit trail.

Concurrent Reviews:\ Medecision Utilization Management is equipped to manage concurrent reviews, which involve ongoing assessment and monitoring of the care provided to patients during their hospital stay or treatment period. The system enables real-time tracking and documentation of clinical information and decisions made during the review process. It facilitates communication and coordination between the review team, the attending physician, and other members of the care team to ensure the ongoing appropriateness and necessity of the care being provided.

The system includes monitoring and reporting capabilities for Turn Around Time (TAT), ensuring efficient and compliant utilization management processes. This comprehensive approach ensures that UM requests are managed effectively and in compliance with regulatory standards.

TAT Thresholds: Medecision Utilization Management platform allows healthcare organizations to define TAT thresholds for each stage of the utilization management process. These thresholds signify the desired time within which each stage should be completed. For example, the TAT threshold for assigning a case to a reviewer might be set at 24 hours, and the TAT threshold for rendering a decision could be set at three business days.\ Alerts and Notifications: Medecision Utilization Management can generate alerts and notifications based on defined TAT thresholds and bottlenecks. For example, if a case has not been assigned to a reviewer within the specified time, the case can be escalated and alerts can be sent to the appropriate individuals, ensuring timely action and resolution. These alerts help teams stay on track and address any delays or compliance issues promptly.\ Monitoring and Reporting: Medecision Utilization Management includes monitoring and reporting capabilities for Turn Around Time (TAT), ensuring efficient and compliant utilization management processes.

Our platforms and software solutions use various mechanisms to stay up to date with changing state and federal requirements.

By keeping the platform up to date, we help our clients ensure their utilization management processes remain compliant, reduce the risk of non-compliance penalties, and provide high-quality care aligned with the latest regulatory standards.

Medecision Utilization Management is designed to seamlessly integrate with existing Case Management solutions, with support for data feeds, data streams, RESTful APIs, and FHIR standards—enabling coordinated care and streamlined workflows across platforms. Our platform's Utilization Management and Care Management (Member Management) also seamlessly operations off the same Medecision Platform. The unified platform enhances collaboration and facilitates efficient sharing of information across both modules, optimizing care outcomes and ensuring a holistic approach to member management.

Yes, the Medecision platform has the ability to flag potential high-cost members based on claims. This feature however presumes extended capabilities into our data platform and/or our Care Management solution. Flagging high cost members requires claims ingestion which is not necessary for pure Utilization Management. We are happy to discuss this capability further and expand on our other solutions as neecssary.

Bi-directional provider portal: Medecision's provider portal simplifies the prior authorization process for healthcare providers, allowing them to submit and track authorization requests seamlessly. The user-friendly interface ensures ease of use, while real-time tracking and notifications keep providers informed of the status of their requests, enhancing efficiency and collaboration.

Medecision's Provider Portal streamlines the authorization and referral process, giving select providers direct access to submit, review, and escalate requests—enhancing efficiency and accelerating care. The following represents a few key features and benefits:

Key Features:\ • Simplified Provider Access: Providers or provider groups gain secure access through a standard onboarding process. Once onboarded, they can submit and track prior authorization requests in real time.\ • Fast & Secure Authorization Submission: Providers can submit prior authorization requests directly, reducing administrative delays.\ • Self-Review with Predefined Criteria: Built-in medical necessity questionnaires ensure compliance and allow for real-time auto-approval when criteria are met.\ • AI-Driven Decisioning: Medecision automates approvals when possible; if the pre-defined criteria is not met, the request is seamlessly escalated to BCBSAL for further review.

Key Benefits:\ • Accelerates approvals, reducing wait times for members.\ • Ensures compliance with clear, standardized self-review guidelines.\ • Enhances transparency and provider autonomy while maintaining payer oversight.

With our intelligent Provider Portal, healthcare providers gain the power to manage authorizations efficiently, ensuring faster decisions and better member outcomes.

The system supports appeals and grievance management through a detailed process that includes initiation, communication, review, decision making, documentation, automation, and reporting.

Throughout the process, the system allows for the completion of questionnaires and notes, and it supports the identification of the appeal level, urgency, type, and reason for the appeal. The system also provides automation for reassigning appeals and generating communications based on predefined rules or criteria, ensuring that appeals are directed to the right department or agent for resolution.

Additionally, the system includes monitoring and reporting capabilities for Turn Around Time (TAT), ensuring efficient and compliant utilization management processes. This comprehensive approach ensures that appeals are managed effectively and in compliance with regulatory standards.

When an appeal or grievance has to be shared with an external reviewer, the request and the appeal or grievance summary from Medecision, along with any associated letters and attachments, can be printed or downloaded and shared with the external reviewer, typically via their portal.

Additionally, the system includes monitoring and reporting capabilities for Turn Around Time (TAT), ensuring efficient and compliant utilization management processes. This comprehensive approach ensures that appeals and grievances are managed effectively and in compliance with regulatory standards.

At Medecision, we proudly own and meticulously develop nearly all aspects of our platform and solutions in-house, ensuring they meet the highest standards of quality and innovation. For certain specialized functionalities, such as the correspondence and letter template solution presented to Texicare, we strategically partner with a select third party to enhance our offerings. These collaborations are carefully chosen to maintain our commitment to delivering exceptional, comprehensive healthcare solutions.

Yes, Single Sign-On (SSO) is supported through industry-standard protocols, specifically leveraging SAML 2.0. Our platform seamlessly integrates with various identity providers (IdPs), including but not limited to Azure Active Directory, Okta, Ping Identity, and Google.

Medecision Utilization Management (UM) is designed to support streamlined and efficient care management processes, including gold carding—where high-performing providers or low-risk patients bypass certain traditional utilization review steps to enhance efficiency and trust. Here's how Medecision UM facilitates gold carding:

Customizable Authorization Rules: Medecision UM allows organizations to define and implement tailored rules for gold carding. Providers or members who meet specific criteria—such as demonstrated history of quality care delivery, low denial rates, or consistent compliance—can automatically bypass certain pre-authorization processes.

Advanced Analytics and Stratification: Medecision UM leverages predictive analytics to stratify providers and members based on risk, behavior, and performance metrics. This data-driven approach ensures gold carding is applied appropriately, minimizing unnecessary reviews while maintaining high standards of care.

Adaptable Workflow Automation: The platform automates workflows for providers or members flagged for gold carding. This enables faster approvals, reduced administrative burden, and improved overall efficiency for high-priority providers.

Seamless Integration with Policies: Medecision UM integrates gold carding with existing utilization management policies and guidelines, ensuring a cohesive and scalable approach to care management that aligns with organizational goals.

Improved Provider Relationships: By enabling gold carding, Medecision UM fosters trust and collaboration between payers and providers. Providers who consistently deliver high-quality care are rewarded with reduced administrative hurdles, promoting long-term partnerships.

Real-Time Decision Support: The solution provides real-time decision-making tools, ensuring gold carded providers or members receive rapid approvals while maintaining compliance with regulatory and plan standards.

Yes, our solution has the ability to store and version history within our playform so you know what version is being used through the UM process.

No, we are not a drafting medical policy platform.

Yes, our UM solution is interoperable and compliant with CMS regulation.

Yes, our UM solution is CRD compliant. Providers are able to check if prior authorization is required and confirm service is covered.

Yes, our UM solution is DTR compliant. Our UM solution will gather and submit required documentation for requests are required by CMS.

Yes, our UM solution is PAS compliant. Providers can submit authorization requests and learn the outcome. This capability will greatly reduce provider burden and manual work.