Question 1

Our delegated-UM process has its own quirks. What gets adapted, and what stays the same for our team?

Accepted Answer

UM-portal agents are built against your specific UM vendor mix, so the forms, review states, and re-check cadence are scoped to each portal. Your side stays familiar: inputs are the member, provider, and service details you already collect, credentials live in an agent profile you control, and results (tracking number, review status, every status change in the portal's exact wording) return in your output format. Pended-auth re-check schedules and escalation routing follow your SOP. Scoping against your UM mix is where those rules get set.

Question 2

What access and integrations do the UM portals require?

Accepted Answer

A credentialed account per UM portal. Delegated UM means one more system per payer relationship, and each is signed into with credentials held in an agent profile. Inputs come from your existing PA worklist; the tracking number, review status, and scheduled status-change reports flow back to it as structured output. No UM-vendor API is required; the agent works the portal the way your staff would. Credentials are scoped least-privilege and can be rotated or revoked per portal without touching the others. Full posture on the security page.

Question 3

What stops a run on a UM portal, and how does the handoff work?

Accepted Answer

A missing required field is a named failure: the run stops citing the field, never guessing. A question the inputs don't answer is reported by name; the agent never invents clinical information, and those cases go to clinical staff. A peer-to-peer review request, a demand for more information, or anything the portal disputes goes to a person immediately with the reviewer's actual ask attached. Portal changes (login flows, MFA, new screens) surface as reported technical exceptions rather than silent misfires, distinct from business outcomes like a pend.

Question 4

How do we track and audit authorizations that sit in clinical review for weeks?

Accepted Answer

That waiting period is exactly what this workflow instruments. Every submission captures the tracking number and review status, and pended authorizations are re-checked on schedule, with each status change reported in the portal's exact wording, so your audit trail shows what the reviewer said and when, not what someone remembers. A pend, a request for more information, or a denial is a successfully captured business outcome; a portal error is a separate technical exception. Your team receives the changes instead of doing the checking.

Question 5

How is a utilization-management portal workflow different from a payer-portal submission?

Accepted Answer

By where the payer sent the authorization. When a payer delegates utilization management, the request leaves the payer's portal entirely and is submitted, reviewed, and tracked on the UM vendor's own system: its own credentials, forms, and review states. This workflow follows the authorization there, including the long 'pending clinical review' stretch where re-checking on schedule matters most. The payer-portal workflow and the clearinghouse-style workflow cover the non-delegated doors.

Question 6

What happens when the case routes to another reviewer or the portal asks a new branch of questions?

Accepted Answer

New questions are answered only from your inputs: a question the provided documentation doesn't cover is reported by name and the run stops there; the agent never fills a gap with an invented clinical answer. A peer-to-peer review request or a demand for more information escalates to a person immediately, carrying the reviewer's actual ask so your clinical staff respond once, with context. Meanwhile the tracking number and current review status stay captured, so the case re-enters the scheduled re-check loop after the human step.

Prior Authorization on Utilization-Management Portals

See it run on your systems.

Following the authorization onto the UM vendor's own system

“Pending clinical review” needs a schedule, not a watcher.

What runs today

Frequently asked questions