InsuredAudit turns utilization management from a defensibility liability into a documented asset. Each authorization, concurrent review, and denial is tied to the exact clinical criteria applied, reproducible on demand, and packaged as evidence your auditors, regulators, and appeals reviewers can stand behind.
A member portal that turns a denial into an answer: the money their plan moved, a visual timeline of every record, and -- for every denial -- why, how it compares to the applicable rule, and exactly how to overturn it.
Improper-denial scrutiny, appeals overturn rates, and regulatory audits all turn on one question: can you show, decision by decision, that the right criteria were applied consistently? When the answer lives in scattered notes and reviewer memory, every appeal and every audit is a risk you carry alone.
When a denial is reversed and no one can reconstruct the criteria applied, the loss compounds: the cost, the abrasion, and the precedent.
State DOI reviews and CMS program audits read silence as non-compliance. An incomplete record is treated as an absent one.
The same case, two reviewers, two outcomes. Without an anchored criteria trail, drift is invisible until it is litigated.
InsuredAudit sits alongside your existing UM workflow and your clinical criteria, capturing the substantiation for every determination as it is made. AI accelerates the work; deterministic rules, the applied criteria, and your reviewers determine the outcome.
Every determination is bound to the specific criteria set and clinical inputs that produced it, so the rationale is explicit and reproducible.
Each decision produces a tamper-evident evidence record built to survive appeal, audit, and litigation scrutiny, not just internal review.
Models draft, summarize, and surface; they never decide medical necessity. Outcomes rest on criteria and qualified reviewers, which keeps the record defensible.
Walk into any audit or appeal able to reconstruct exactly why a decision was made, on the criteria, every time.
Replace "we believe our process is sound" with a record you can produce, page for page, on demand.
Reduce overturns, rework, and audit exposure by closing the gap between the decision and its documentation.
We map your UM workflow, criteria sources, and the decisions under the most scrutiny.
We run a sample of real determinations through InsuredAudit and show the evidence record each one produces.
We put those records up against appeal and audit standards so you see how they hold under challenge.
You see the defensibility gain on your own cases before any commitment.
InsuredAudit runs inside your environment and connects to the systems you already have. Send your claims, prior-authorization, appeal, and pharmacy data through a REST API or native EDI/FHIR (X12 837/835/278, FHIR, HL7v2, NCPDP), and read back timelines, guideline checks, and court-ready evidence bundles. Scoped API keys, webhooks, and SDKs for TypeScript and Python.
Bring your hardest UM cases. We will show you, on your own determinations, what defensible utilization management looks like.
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