Agentic AI Utilization Management for Payers
Smarter Utilization Management for Better Decisions, Simpler Reviews, and Faster Access to Care
Modernize utilization management with an AI-powered platform that streamlines review workflows, applies plan-specific criteria, and helps health plans deliver faster approvals, lower costs, and better provider and member experiences.
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Innovaccer is trusted by leading healthcare organizations to improve outcomes
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End-to-end utilization management, built for speed and compliance.
Agentic AI automates the full UM lifecycle, helping teams move faster while reserving clinical judgment for the cases that need it.
INTAKE & DATA EXTRACTION
Every request is captured and normalized across channels
- FHIR API, provider portal, EDI X12 278, and fax/OCR
- NLP extracts clinical evidence from unstructured documents
- Eligibility verified at intake, with immediate tracking
MEDICAL NECESSITY EVALUATION
Qualifying requests are approved in real time. All others are escalated, never auto-denied.
- AI evaluates against plan-specific medical necessity criteria
- Configurable by CPT code, line of business, and gold-card programs
- Non-qualifying cases are routed with an AI-prepared clinical summary, helping reviewers move faster and members access care sooner.
CLINICAL REVIEW WORKFLOW
Reviewers decide, not search.
- Every case is pre-analyzed, deadline-tracked, and aligned to timely member care.
- AI-prepared summary, with evidence extracted and criteria gaps identified
- Worklist prioritized by urgency and review timeline
- Physician peer review is enforced for all adverse determinations
PROVIDER COMMUNICATION
Every decision reaches providers quickly and clearly.
- Determination letters are auto-generated and sent via portal, email, or fax
- Providers are notified quickly of approvals, denials, and additional information requests
- Provider portal gives real-time status visibility, reducing inbound inquiry volume
- Site-of-care guidance included with authorization responses
COMPLIANCE, ANALYTICS, AND REPORTING
Full visibility into performance, compliance, and turnaround readiness.
- Real-time dashboard across approval rates, turnaround times, cost per PA, and denial trends
- Automated turnaround tracking across all lines of business
- Denial reasons documented with appeal rights included
- PA metrics report available on demand
- Surfaces avoidable utilization trends, including unnecessary imaging and procedures
CUSTOMER SUCCESS
Leading Healthcare Organizations Choose Innovaccer
Abdou Bah
Chief Health Equity Officer of EmblemHealth
Scott Maron, MD
President, Atlantic Health ACO
"InNote saves me 30 minutes a day that I would have otherwise spent chasing down information."
- $1M in potential incentive payments
- 10% improvement in coding gap closure rate
- 30 minutes a day saved per provider
Nick Moriello
President of Highmark Blue Cross Blue Shield Delaware
"By making data more accessible and accurate, and using AI in practical ways, we can actually solve the day-to-day."
Banner Health is one of the nation's largest payer-provider organizations, managing 1.4M patients in value-based arrangements across Arizona and Colorado. Banner partnered with Innovaccer to integrate data from disparate sources, surface insights at the point of care, and create a system wide strategy for succeeding in value-based care.
- 18% care gap closure rate
- 1.4M lives covered by value-based care
- $4M saved through vendor consolidation
Built to support compliance, transparency, and audit readiness.
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HIPAA compliant, HITRUST certified, SOC 2 Type II, and NCQA-certified
Designed to support CMS-0057-F requirements and URAC audit readiness
Explainable AI with human oversight at every critical step
Clear rationale, policy support, and audit trails across determinations
See how agentic AI can streamline utilization management and support better member outcomes.
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