Payors / utilization management
Approve Faster, Review What Matters
Many prior-auth requests are approved every time. Ana finds them so they can move out of the queue, and puts reviewers’ time on the few where the evidence is actually in question — with the member’s history attached.
Fixed scope: a year of auth requests and outcomes, run inside your cloud.
Review Everything, or Review What Matters
- Every request in one queue, first in, first out
- Services approved 98% of the time still reviewed
- Overturned denials not fed back into policy
- Turnaround reported after the quarter ends
- Requests sorted by whether they need a clinician
- Always-approved services moved toward auto-approval
- Appeal outcomes read back into the rules
- Turnaround watched by service, this week
Find the Requests That Don’t Need Review
A year of requests and outcomes says which services are approved every time, for which providers. Ana finds them so your medical policy team can decide what moves to auto-approval — and what still needs a look.
- Approval rates by service, provider and diagnosis
- Appeal outcomes read beside the first decision
- Every change decided by your policy team
Which services do we approve almost every time?
Office-based imaging and routine PT are approved over 96% of the time.
- office imaging 98.6%
- routine pt 1.0× office imaging 96.2%
- sleep studies 0.9× office imaging 91.0%
- spinal fusion 0.6× office imaging 62.4%
Put the Evidence in Front of the Reviewer
The requests that need a clinician need context: prior treatment, recent imaging, the policy criteria. Ana attaches the member’s history to each one, so the review starts with the facts, not a records request.
- Prior treatment and imaging joined to each request
- The policy criteria it’s measured against, cited
- Missing documentation named before the review
What does the reviewer need for request PA-88412?
Six weeks of physical therapy is documented; the recent MRI isn’t attached yet.
- 01/08lumbar pain · pcp visit
- 01–02pt · 12 sessions · 6 weeks
- 03/02mri lumbar · result not on file
- 03/09request · lumbar fusion · policy mp-114
Move the Queue, Then Keep It Moving
The review queue shrinks when the rules learn. Ana sends the always-approved services to medical policy, the overturned denials back to the reviewers who made them, and turnaround to the team that answers for it.
- Auto-approval candidates to medical policy
- Overturn patterns back to review teams
- Turnaround and outcomes ready to report
What should change in the queue this quarter?
42 services proposed for auto-approval; two denial patterns sent back for review.
- med. policy 42 codes approved over 98% of the time
- reviewers PT denials overturned 61% of the time on appeal
- providers 120 providers with a 99% approval record
- compliance Prior-auth metrics for public reporting
Sort Your Review Queue
Bring a year of auth requests, decisions and appeals. We join them inside your cloud and hand your UM team the services that don’t need review — and the ones that do.
- 01A 30-minute call to pick the services and lines of business in scope
- 02We connect inside your cloud under a BAA — nothing leaves your environment
- 03Your UM and medical policy teams review the findings with us
Where UM Starts
- 01 Auto-approval candidates
Services and providers approved nearly every time, found from a year of decisions, for your policy team to decide on.
- 02 Turnaround monitoring
Days to decision by service and urgency, watched weekly against your targets.
- 03 Appeal and overturn analysis
Which denials get overturned, by service and reviewer, read back into the rules.
- 04 Review packet preparation
The member’s history and the policy criteria attached to each request that needs a clinician.
- 05 Prior-auth reporting
Approval, denial and turnaround metrics by service, ready for public reporting.
- 06 Provider gold-carding
The providers whose requests are approved every time, shortlisted with their record.
No. Clinicians and your medical policy team make every decision. TextQL sorts the queue, attaches the evidence and shows which rules could change.