Every medical-necessity decision, criteria-anchored and court-ready.
InsuredAudit turns utilization management from a defensibility liability into a documented asset -- and gives members a plain-English, government-rule-anchored answer to every denial. Accountability, auditability, and transparency, by design.
The problem
Improper-denial scrutiny, appeals-overturn rates, and CMS / state audits all turn on one question: can you show, decision by decision, that the right criteria were applied consistently? When that record lives in scattered notes and reviewer memory, every appeal and audit is a risk the plan carries alone -- and every member is left without an answer.
Why now
The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) phases in for impacted payers, including Medicare Advantage, Medicaid and CHIP managed care, and ACA exchange plans, through 2026 and 2027. It requires a specific reason for every prior-authorization denial, shorter decision windows, and public reporting of approval, denial, and turnaround metrics. Appeals, state fair hearings, and external quality review will test each of those numbers. InsuredAudit gives you the decision-level record behind each one.
What InsuredAudit does
Criteria-anchored decisions
Every authorization, concurrent review, and denial is bound to the exact clinical criteria applied -- explicit and reproducible on demand.
Court-ready evidence (CREB™)
Each decision produces a tamper-evident, signed evidence record designed to support appeal, audit, and litigation review.
A second check on every denial
Find the denials your own criteria do not support before a member, an ombudsman, a fair-hearing officer, or a plaintiff does. InsuredAudit flags determinations that conflict with the criteria you applied, so you correct them upstream, cut avoidable overturns, and keep a sealed record for every denial you uphold. Members get a plain-language explanation of every decision.
AI for speed, not the verdict
AI drafts and surfaces; deterministic rules, the applied criteria, and qualified reviewers decide, so every determination is reproducible and explainable. Admissibility depends on applicable law and procedure.
Not a log viewer: a second check on every denial, against the plan's own published criteria.
Built for your environment
- Deploys inside your infrastructure -- PHI never leaves your HIPAA boundary; compliance is inherited from your environment.
- Connects to systems you already run via REST or native X12 (837/835/278), FHIR, HL7v2, NCPDP -- no proprietary format required.
- Scoped API keys and webhooks. The REST API and its OpenAPI specification are public; TypeScript and Python SDKs are provided to customers and pilot partners on request.
- Tamper-evident audit ledger + signed evidence bundles for every determination.
Who it's for
The value
Fewer avoidable losses
Cut overturns, rework, and audit exposure by closing the gap between the decision and its documentation.
Defensible by design
Walk into any audit or appeal able to reconstruct exactly why a decision was made, on the criteria, every time.
Transparency that builds trust
Members get a real answer instead of a form letter -- reducing abrasion, complaints, and regulatory friction.
Evidence, not assurances
Replace "we believe our process is sound" with a record you can produce, page for page, on demand.
Start with four no-fee working sessions.
What a pilot looks like, on your own historical determinations, before any commitment:
- You bring your hardest UM cases and the criteria sources you applied.
- We bind each determination to the criteria it cites.
- You see which determinations your own criteria do not support, and your overturn exposure.
- You decide whether to scope a program, against the published pricing and your own numbers in the ROI model.
Book a health-plan briefing at insuredaudit.com/connect.