Utilization management automation that ranks every prior authorization request by the time left on its clock
No missed 72-hour or 7-day deadline, and the yearly metrics from the same data.
See one case, screen by screen ↓Software a health plan’s UM team uses to receive prior authorization requests, review them against the plan’s criteria, decide them and notify the provider and member inside the regulatory clock. Utilization Management Automation puts every open request from every channel on one board ranked by time left, with agents reading, chasing, predicting and routing so reviewers spend their time on the decision.
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Since 1 January 2026 a Medicare Advantage, Medicaid or CHIP plan has 72 hours to decide an expedited request and 7 calendar days for a standard one, and the clock starts when the request arrives — not when someone files it. Requests come in by provider portal, four fax lines, phone and mail, each into its own queue, and nobody sees the whole picture by time left until a deadline has gone.
The rest of the clock leaks away in pends. The record a nurse needs is asked for hours after the pend, chased by hand, and for a contract provider’s records no extension is allowed. When the clock is short and the nurse is unsure, the request goes up to a medical director by default — so physician time goes to cases a nurse could approve, while the yearly public metrics put the plan’s turnaround times in front of members, brokers and regulators.
Estimated split for a typical expedited request, worked by hand across channel queues and with the solution. Hours, not days.
Six agents set every clock at receipt, chase missing records and route each request; nurses approve and physicians decide every denial.
Walter Kaminski, 78, broke his left hip and had a hemiarthroplasty at Harlow Point Regional Hospital. On Friday afternoon the hospital faxed a request for 14 days at Cedar Glen Rehabilitation & Nursing. Here is what happens on Monday morning, screen by screen, in the working solution.
Teresa runs the board for a nine-nurse shift at Northbourne Health Plan. 214 open requests sit on one board, each a bar that burns down in real time: 23 expedited inside the red 72-hour window, 183 standard, 8 extended, 40 waiting on records. The horizon above the list places every request as a tick at its deadline, so the shape of the whole queue is visible at once.
“Every clock starts when the request arrives, whatever the channel.”
Joanne faxed a 23-page request for a 14-day skilled nursing stay. On page 2 the hospitalist, Dr. Anita Sorensen, ticked Expedited and signed. The fax line’s old rules read the cover page only and filed it standard — due Fri 16 Oct. Without the board it would have been opened on Wednesday, two days late.
“Expedited — applying the standard time frame could seriously jeopardize the patient’s life, health or ability to regain maximum function.”
The intake reader re-reads the 38 faxes filed as standard since Friday — every page, not only the cover — and finds the ticked box and the signature. The clock keeper restarts the clock as expedited from the fax’s arrival stamp: received Fri 9 Oct 14:12, due today at 14:12, four hours left. Mr Kaminski’s request jumps to the top of the board in red.
Clock keeper restarted the clock as expedited, from receipt — “received Fri 9 Oct 14:12 → due today 14:12 · 4 hours left”.
The outcome predictor reads the record against the plan’s criteria: five-day inpatient stay, daily physical and occupational therapy ordered, lives alone up 14 steps. Approve likely, 89% — within a nurse’s authority, no medical director needed. The reviewer router puts it first in Teresa’s lane, and she presses Take the top request.
The prediction orders the work and picks the reviewer. It never decides.
One record is missing: the physical therapy evaluation of 8 October. The chaser asks Joanne Pike for that document by portal message and fax, with a follow-up at 11:14 and a call script for Marcus Delgado, the intake coordinator, if nothing arrives by 12:14. Teresa checks whether she could buy time — she cannot.
“No rule allows an extension here. Harlow Point Regional Hospital is a contract provider and Walter Kaminski has not asked for one.”
Six fax pages from Harlow Point are matched to the request by member and date. Walks 15 ft with a walker, moderate assist for transfers; the therapist recommends a skilled nursing facility. The prediction rises to approve likely, 94%, with all four criteria supported, and nothing is left on the missing list.
Teresa approves 14 days at Cedar Glen from Mon 12 Oct, with a concurrent review on day 10, Thu 22 Oct. The hospital, the facility’s admissions team and Mr Kaminski — by phone, then by letter — are told at once, under her name and approval authority. Decided with 2 h 34 m to spare, 69 h 26 m from receipt.
Nurses approve. Only a physician may deny or approve in part, with the specific reason.
The decision is written to the timeliness record as it is made: received Fri 9 Oct 14:12, decided Mon 12 Oct 11:38, notice 11:39, expedited, 69 h 26 m elapsed, no extension, decided by Teresa Molloy, RN, on time. It exports in the audit layout in one click.
“Written as each decision is made; nobody can edit a time.”
All nine figures 42 CFR 422.122 asks a plan to post are computed from every decision as it is made — standard and expedited approvals and denials, approvals after appeal, extended requests approved, and average and median time to decision — by contract and for the Medicaid plan. The agent drafts the page; compliance publishes it.
“No missed 72-hour or 7-day deadline since go-live — 31,406 decisions from 13 Jul.”
Routing by prediction keeps 27 requests a nurse can approve with nurses. 31 requests need a physician today — 11.2 hours of review against 14.5 hours on shift — and Dr. Barrow, Dr. Adeyemi and Dr. Lindgren have 3.3 hours to spare for peer-to-peer calls. Switch routing off and it is 58 requests and 21.0 hours, 6.5 hours short.
The same Monday morning, seen by the five people who carry the clock — in their own words, and what their day looks like now.
Six agents set every clock at receipt, chase missing records and route each request; nurses approve and physicians decide every denial.
Reads every portal form, fax, phone note and letter; finds the member, provider, service, codes and any urgency marker on any page; matches records to open requests and merges duplicates.
Sets each clock from the plan’s rules by line of business — 72 hours and 7 days, 24 and 72 hours for Part B drugs — starting at receipt, ranks the board by time left and raises breach alarms.
Names the exact record a decision needs, asks the provider by its own channel — portal message, fax or a call script — and follows up on cadence; noncontract providers within 24 hours.
Predicts approve, partial or denial from the plan’s criteria and the record, with a confidence and the factors for and against, and the type of reviewer the request needs.
Assigns each request to the next free reviewer — nurse, medical director, pharmacist or behavioral health — whose licence, state, skill and load fit it.
Writes receipt, decision and notice times for every decision to the timeliness record and computes the nine yearly public prior authorization metrics by contract and plan.
Nurses approve; only a physician denies. The agents propose; a named person decides.
Anyone on the shift can ask in plain words — what could breach today, why a request moved, how much physician time is needed. Every answer cites the record it rests on.
Why did Walter Kaminski’s request jump to the top?
Because its clock was wrong. Harlow Point faxed it on Fri 9 Oct at 14:12; the cover page reads like a routine request, so the old fax rules filed it standard, due Fri 16 Oct. On page 2 Dr. Anita Sorensen ticked Expedited and signed. The 72 hours run from receipt, not from filing — so it is due today at 14:12. Predicted: approve, a nurse can decide; the PT evaluation was asked for at 10:14.
Which requests could breach before 18:00 today?
Every open request with a deadline before 18:00, with its due time and who has it. Marcus Tillery’s fusion is the one to watch: Dr. Barrow’s peer-to-peer call is at 13:00. The board is filtered to today.
How much medical director time do we need today?
31 requests are predicted to need a physician — 11.2 hours of review against 14.5 hours on shift. Without routing by prediction it would be 58 requests and 21.0 hours, 6.5 hours short. The 27 requests a nurse can approve stay with nurses; a possible denial still always goes to a physician.
Draft the expedited figures for the 31 March posting
For Medicare Advantage contract H5821, 1 Jan to today: 94.1% of expedited requests approved and 5.9% denied; average 29.6 h, median 22.4 h to a decision. No expedited decision has been late since go-live on 13 Jul. The draft page is open — nothing is posted until compliance signs it.
13 screens from the working solution, on its sample data. Pick one to see it large.
Clocks by line of business, alerts, chasing and routing are settings owned by the UM operations manager. A change applies to requests that arrive after it.
| Setting | Default | Choose from |
|---|---|---|
| Medicare Advantage · items and services | 72 h expedited · 7 days standard | Extension up to 14 days, rule-bound (42 CFR 422.568, 422.572) |
| Medicare Advantage · Part B drugs | 24 h expedited · 72 h standard | No extension |
| Medicaid and CHIP managed care | 72 h expedited · 7 days standard | Up to 14 days, justified (42 CFR 438.210(d), 457.1230) |
| Breach alarm to the shift lead and manager | 2 h left | 1 to 8 h |
| Re-read faxes filed as standard | Every 2 hours, every page | On · off |
| First ask for a missing record | Within 1 h expedited · 4 h standard | Within 30 min · 2 h, or 2 h · 8 h; follow up every 4 h · 24 h or 2 h · 12 h |
| Nurse lane threshold | 80% predicted approval | 60 to 95%; below goes to a medical director |
| Who may deny | Medical director only | Any adverse or partial decision; Part B drugs reviewed first by a pharmacist |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample plan data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (CMS-0057-F fact sheet — 72 hours expedited, 7 calendar days standard from 1 Jan 2026; KFF, Medicare Advantage prior authorization 2024 — 80.7% of appealed denials overturned). Regulations are named as context. People, plans, hospitals and members named on this page are fictional — characters and sample data in the working solution.
Software a health plan’s UM team uses to receive prior authorization requests, review them against the plan’s criteria, decide them and notify the provider and member inside the regulatory clock. Utilization Management Automation puts every open request from every channel on one board ranked by time left, with agents reading, chasing, predicting and routing so reviewers spend their time on the decision.
The clock starts at receipt, whatever the channel, and the board is always sorted by time left. Faxes filed as standard are re-read on every page every two hours for an urgency box or signature, a breach alarm goes to the shift lead and manager at 2 hours left, and a reviewer who presses Take the top request always gets the one with the least time left that they may decide.
No. The outcome predictor only orders the work and picks the reviewer type; it never decides or drafts a denial. Nurses approve within their authority, and any adverse or partial decision is made by a medical director with the specific reason.
No agent stops, pauses or extends a clock — the bars keep moving while a request is pended. Extend is offered only when the member asks, or records from a noncontract provider could change a denial; a person decides and the notice is drafted. Part B drug clocks are never extended.
Yes. The metrics reporter computes the nine figures 42 CFR 422.122 lists — by contract and for the Medicaid plan — from every decision as it is made, and drafts the page for the 31 March posting. Compliance reviews and publishes it.
Your provider portal, fax lines, UM phone line and scanned mail for requests and records; your shift roster with reviewer licences, states and skills; provider contact details; and your medical policies and criteria. Clock rules are set per line of business: Medicare Advantage, Part B drugs, Medicaid and CHIP managed care.
Yes. Agents read, set clocks, chase, predict and route; people decide. Thresholds, cadence and routing rules are settings owned by the UM operations manager, every change is versioned, and every person and agent action is on the timeliness record.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your clock rules, criteria, roster and a sample of past requests — and it goes live once every quality gate has passed. We will walk you through it on your own requests first.
Every criterion shown met or not met, with the page that proves it.
1-min demoAppeals & Grievances ManagementEvery appeal decided on time, with the full file read and what is new marked.
1-min demoMedical Policy SearchThe criteria that apply, with the policy section and version that say so.
1-min demoWe’ll run Utilization Management Automation on a sample of your own requests and decision record.