Clinical documents are read by hand
An analyst spends 15 to 30 minutes on an operative note to decide whether it supports what was billed. Two analysts reading the same note do not reliably reach the same determination.
Solutions / Utilization & Clinical Review
Clinical review at the
speed of adjudication
Utilization management carries some of the largest exposure in healthcare administration. CMS-0057-F now puts hard deadlines on prior authorization, and every denial has to hold up years later, long after whoever made it has moved on.
The problem
What gets
in the way
Regulatory clocks are now hard
CMS-0057-F sets decision deadlines with real consequences for missing them. Manual review capacity does not flex to meet a statutory clock.
Denials have to survive appeal
A determination that cannot show the clinical evidence it relied on is one that gets overturned, often years later, at an administrative hearing.
How we solve it
What we do
about it
The note is parsed before a model sees it
Deterministic extraction pulls structure out of the document first. The clinical model reasons over that structure instead of the raw page.
Every determination cites the record
SUPPORTED, NOT SUPPORTED or INSUFFICIENT, each one quoting the lines it relied on. An appeals reviewer can trace any conclusion back to the page it came from.
Denials always reach a physician
Medical-necessity denials route to human sign-off. That rule sits at the platform level, and no administrator setting turns it off.
What you get
What changes
for your team
- An operative note becomes a cited determination in roughly three seconds instead of half an hour
- Every determination is SUPPORTED, NOT SUPPORTED or INSUFFICIENT, and quotes the record word for word
- Medical-necessity denials always route to a human physician for sign-off. That rule is encoded at the platform level and cannot be overridden by an administrator
- The evidence chain is sealed into an immutable audit trail, exportable as a defense package for an ALJ proceeding
- Shadow mode runs the agents alongside your analysts and compares determinations before anything is activated
The agents
3 agents
do this work
Each one is trained, tested and audited on its own, built from the same skill library and governed the same way as everything else on the platform.
Who uses it
- Third Party Administrators Prior authorization and medical-necessity review for the plans you administer, each determination citing the record
- Health Plans An operative note becomes a cited determination in about three seconds, and medical-necessity denials always reach a physician
- Brokers High-cost episodes are reviewed against the clinical record, and every determination cites it
Next step
See it on your
own data
We run your historic records through the agents and show you what each one finds, with its evidence, before anything is switched on.