For Plan Sponsors & TPAs
Delegated utilization management with clinical rigor, clear SLAs, and transparent reporting— tailored for self-funded employers, TPAs, and regional health plans.
Core UM Modules
Prior auth, concurrent/retro review, post-acute review, DME/therapy, appeals coordination, peer review scheduling.
Clinical Oversight
RN reviewers with medical director oversight; guideline use aligned to your policies (e.g., InterQual/MCG) and benefit plan language.
Quality & Compliance
HIPAA safeguards; CMS/NCQA/URAC-aligned processes; audit trails; ongoing QA & inter-rater reliability checks.
Reporting
- • Volumes by line of business & service category
- • Decision turnaround times vs. SLAs
- • Approval/denial rates with rationale categories
- • Appeals outcomes & peer-to-peer metrics
- • Site-of-care shifts & post-acute utilization trends
Program Benefits
- • Cost containment through appropriate utilization
- • Member experience via faster, clearer determinations
- • Provider satisfaction with predictable processes
- • Operational transparency and audit readiness
Implementation & Governance
1) Discovery
Policy alignment, benefits, LOBs, and integration points.
2) Configuration
Criteria sets, letter templates, SLAs, escalation paths.
3) Pilot
Limited rollout with QA sampling and reporting validation.
4) Go-Live
Steady-state operations with governance reviews & KPIs.