AI Agents-Utilization Management Agents

Slash Prior Auth Turnaround
Automate Intake. Cut UM Staffing 40–60%.

AI-driven intake-to-determination workflow that meets every CMS and state SLA while dramatically reducing operational cost.

What Are UM AI Agents?

UM AI Agents automate the complete prior authorization lifecycle from any-channel intake through clinical evidence assembly, guideline application, and final determination. They replace the manual, multi-system process that currently consumes 40 minutes per intake case and hours of clinical reviewer time with an intelligent, end-to-end workflow that meets every CMS and state SLA.
CareInsight’s UM Agents operate as a connected four-stage workflow Intake, Notify, Evaluate, and Determine — with human-in-the-loop design ensuring clinicians make every final decision while AI eliminates all administrative and data-gathering burden.

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Our UM AI Agents

Intake Agent

UM / Prior Authorization

Purpose

Receives prior authorization requests from any channel — call, fax, portal, mail. Auto-classifies request type, checks for expedited status, verifies member eligibility, validates provider credentials, and creates a fully documented case in under 2 minutes. Sends acknowledgement and requests missing clinical documentation via omni-channel outreach. Replaces a 40-minute manual process with 95% automation.

Key Benefit

Every prior auth case is intake-stamped, eligibility-verified, and credential-checked in under 2 minutes — from any channel, with zero manual data entry. Fully compliant with MA and Medicaid audit requirements from the first touch.

42 CFR §422.568 §438.210 CMS-0057-F

⚡ 95% Intake Automation — 40 min → 2 min

Omni-Channel Notification Agent

UM / Administrative

Purpose

Automates all mandated communications throughout the UM lifecycle — receipt acknowledgement, missing document requests, and determination notifications. Delivers via mail (multi-language), SMS, email, and conversational AI calls to both members and providers. Ensures every notification is compliant, timestamped, and audit-ready for CMS and state regulatory review.

Key Benefit

Eliminates manual calling and letter generation across every UM notification touchpoint. Saves 75% of administrative notification time while guaranteeing zero missed acknowledgement deadlines — for both MA and Medicaid mandates.

MA & Medicaid Multi-Language Omni-Channel

⚡ 75% Administrative Notification Time Savings

UM Evidence Retrieval & Recommendation Agent

UM / Prior Authorization Clinical Review

Purpose

Automatically aggregates clinical evidence from claims platforms (QNXT, TriZetto, Facets), authorization history, member records, provider credentialing, fee schedules, clinical guidelines (InterQual/MCG), LCD/NCD criteria, NCCI edits, and FWA analytics. Generates an evidence-based recommendation with confidence scoring. Supports custom GoldCarding rules by payer. Routes auto-approval directly to resolution if configured, or to MD for final decision with full evidence package already assembled.

Key Benefit

Reduces clinical review workload by 70% — eliminating the manual, multi-system evidence gathering that consumes hours of reviewer time per case. Human-in-the-loop design: AI recommends with confidence scoring, clinicians decide. All denial recommendations include complete evidence summary before MD sign-off.

InterQual / MCG LCD / NCD GoldCarding FWA Analytics

⚡ 70% Clinical Review Workload Reduction

End-to-End AI Workflow

📥 INTAKE — Any Channel, Fully Automated

Any prior auth request — call, fax, portal, or mail — triggers automatic case creation in under 2 minutes with zero manual data entry.

→ Auto-classify request type and check expedited status immediately
→ Verify member eligibility and validate provider credentials
→ Fully documented case created — timestamped and audit-ready
→ AI OCR processes all fax and mail attachments automatically
→ 40-minute manual process replaced with 95% automation

🔔 NOTIFY — Mandated Communications on Autopilot

Every required communication to members and providers is auto-generated and delivered — fully compliant, fully timestamped, zero manual effort.

→ Acknowledgement auto-sent to member and provider on receipt
→ Missing clinical documentation requested via omni-channel outreach
→ Multi-language delivery — mail, SMS, email, AI voice calls
→ Determination notifications auto-delivered post-decision
→ 75% reduction in administrative notification staff time

🔍 EVALUATE — AI Evidence Assembly & Recommendation

The AI agent aggregates clinical evidence from every relevant system and generates a recommendation with confidence scoring — replacing hours of manual reviewer work.

→ Pulls from claims (QNXT, Facets), auth history, member records
→ Applies InterQual/MCG clinical guidelines and LCD/NCD criteria
→ Validates NCCI edits, fee schedules, and FWA anomaly flags
→ Custom GoldCarding rules applied per payer configuration
→ Evidence-based recommendation generated with confidence score

✅ DETERMINE — Auto-Approve or MD-Routed Decision

If criteria are met, auto-approval routes directly to resolution. All denial recommendations go to the MD — with the full evidence package already assembled.

→ Auto-approval configured by payer rules — direct to closure
→ All denials routed to MD with complete AI evidence summary
→ 7-day standard / 72-hr expedited SLA met every case
→ Human-in-the-loop: AI recommends, clinicians decide
→ 40–60% total staffing reduction with improved turnaround times

Why Health Plans Are Moving Now

⚖️

Regulatory Risk

7-day standard / 72-hr expedited decision mandates (§422.568 / §438.210)
CMS-0057-F: Prior Auth API and reduced timelines now required
Auto-approval triggered if plan misses decision deadline
State regulators auditing UM SLA compliance with increasing frequency

💸

Financial Impact

40-min manual intake × thousands of requests = massive bottleneck
Clinical reviewers spend hours gathering evidence before determination
SLA failures erode provider relationships and Star ratings
Missed GoldCarding opportunities = unnecessary clinical review cost

🚀

CareInsight Advantage

Intake-to-case in 2 min any channel — 95% automated
AI evidence assembly replaces hours of manual data gathering
Custom GoldCarding + auto-approval rules reduce unnecessary reviews
40–60% total staffing reduction with improved turnaround times

Where UM Agents Shine

Prior Auth Intake & Triage

Clinical Evidence Retrieval & Assembly

InterQual / MCG Guideline Application

Auto-Approval & GoldCarding Rules

MD Routing with Evidence Package

Mandated Notification Automation

CMS & State SLA Compliance

FWA Anomaly Detection

LCD / NCD & NCCI Edit Validation

100% Audit Trail Coverage

Why Choose Us

HIPAA & CMS Ready

Built to meet HIPAA and CMS standards, ensuring data privacy and regulatory compliance.

EHR-Ready Integration

Works seamlessly with your existing EHR systems without workflow disruption.

Always Improving

Learns from every case to deliver faster, more accurate results over time.

Full Audit Trails

Every action is logged and traceable for clear accountability.

Proven Results

Delivers time savings, fewer errors, and happier teams in weeks.

Ready to Transform Your UM Operations?

Request a personalized analysis see exactly what CareInsight saves your plan.

Schedule a 30-Min Executive Briefing →

Ready to Transform Your UM Operations?

Request a personalized analysis see exactly what CareInsight saves your plan.

Schedule a 30-Min Executive Briefing →