Hospital utilization review
Case management and the UR committee.
- UR plan, committee and determinations
- Admission and continued stay review queues
- Status decisions and required notices
- Physician advisor escalation
Healthcare / Utilization Management
Utilization management software for hospital review teams and health plans
A case manager decides inpatient or observation status with a clock running, while a payer reviews the same stay from the other side. Agnotic Technologies builds utilization management software for both: the hospital's utilization review plan and queues, the plan's review records, and one review history that holds up in an appeal.
Review
Admission and continued stay
Status
Inpatient or observation, with reasons
Record
One review history for appeals
Trusted by global innovators
Industry Overview
What is utilization management software?
Utilization management software records whether hospital admissions, continued stays and services are medically necessary, and who decided. Agnotic Technologies builds it for hospital utilization review teams and health plans: review queues under the hospital UR plan, inpatient or observation status decisions, physician advisor escalation, committee records and one review history for appeals.
Two sides
Which side of the review are you building for?
The hospital and the plan review the same stay with different rules and different records.
Health plan utilization management
Concurrent review of the hospital's stay.
- Concurrent review and approved days
- Peer to peer scheduling and outcomes
- Decision letters
- Workbench and reviewer routing on our payer operations page
Delegated UM vendors and startups
Review work done for several plans or hospitals.
- Client-specific rules and criteria
- Separate records per client
- Reporting each client can audit
Industry Challenges
Where does hospital utilization review lose time?
Most of the losses are records that exist somewhere but not where the reviewer or the appeal needs them.
Case managers screen admissions from a printed census, so a patient who should have been inpatient sits in observation until someone notices.
The physician's reasons for expecting a stay over two midnights are buried in free text, and nobody can find them when a reviewer asks.
Outlier stays that the UR committee must review are found after discharge.
Physician advisor referrals happen by phone and leave no record of the question, the answer or the time.
The hospital and the payer each keep their own version of the same stay, and the appeal is built from screenshots.
Days at risk are counted in a spreadsheet at month end, too late to change anything.
Our Approach
How do we build one review record both sides can trust?
Three design rules carry through every utilization management build.
Every review is an event
Each step stores the criteria reference, the clinical facts used, the reviewer, the time and the outcome. Nothing is overwritten, so the history can be replayed in an appeal.
Status is a decision with reasons
The physician's expectation and the factors behind it sit in structured fields next to the order, where a reviewer can find them.
Payer facts come in, not copies
Authorization numbers, approved days and peer to peer outcomes are stored against the same stay, so the denial and the appeal see one history.
Capabilities
What do we build for utilization management?
Hospital-side modules first, with the payer data each one needs. Prior authorization request exchange is covered on our prior authorization automation page.
Admission review queue
New admissions and observation patients screened against criteria, ordered by time since arrival.
Status decision support
Structured capture of the admitting physician's expectation and its factors, with order checks before status changes.
Continued stay review
Next review dates, approved days and outlier flags for the UR committee, per patient.
Physician advisor escalation
Referrals with the question, the response time and the outcome recorded.
UR committee workspace
Cases for committee review, practitioner consultation, one or two member determinations and notices.
Notice tracking
Observation notices and not medically necessary notices, with delivery time and signature or refusal.
Days at risk reporting
Avoidable and denied days with reasons, by unit, payer and physician.
Payer review record
Authorizations, approved days, peer to peer results and denials linked to the stay and the claim.
Engineering Stack
Which systems and standards does UM software use?
We connect to the EHR and the payer channels you already use.
Hospital data
HL7 v2 ADT and ordersFHIR R4 from the EHRCensus and bed management
Criteria
Licensed criteria sets through vendor interfacesInternal criteria as versioned rules
Payer exchange
X12 278Da Vinci PAS where the payer supports itPayer portals
Platform
Role-based accessEvent-based audit trailEncryption in transit and at restData warehouse feed
Two-sided review
Who does what at each review step, on each side?
The original element of this page: each review step with the hospital user, the payer user, the rule that applies and the record each side must keep. Criteria licensing and the Medicare Advantage UM committee rules are compared on our licensed vs internal UM criteria page.
| Review step | Hospital user | Payer user | Rule that applies | Record each side keeps |
|---|---|---|---|---|
| Admission review | UR nurse or case manager | Plan concurrent review nurse | 42 CFR 482.30(c) for the hospital; the plan's UM policies for the payer | Criteria used, clinical facts, reviewer and time |
| Status decision | Admitting physician, supported by case management | Plan reviewer of the inpatient request | 42 CFR 412.3 two-midnight expectation for Medicare Part A | Order, documented expectation and its reasons |
| Observation notice | Registration or case management | None | 42 CFR 489.20(y) for Medicare outpatients in observation over 24 hours | Notice delivered, time, signature or refusal |
| Continued stay review | Case manager; UR committee for outlier stays | Plan concurrent review nurse | 42 CFR 482.30(c) and (e) | Review dates, approved days and days at risk |
| Physician advisor or peer to peer | Physician advisor and attending physician | Plan medical director | Hospital UR plan; plan UM policies | Question, discussion, outcome and time |
| Not medically necessary determination | UR committee members | Plan physician reviewer | 42 CFR 482.30(d): consult the practitioner, notice within 2 days | Who decided, the consultation and notices sent |
| Denial and appeal | Denials and appeals team | Plan appeals unit | Payer contract and program appeal rules | Full review history linked to the claim |
Measured Impact
What should a UR director see each morning?
Views we build for case management, physician advisors and the UR committee.
Unscreened
Admissions not yet reviewed
New admissions and observation patients waiting for a first review.
Due
Continued stay reviews due
Reviews due today, by unit and reviewer.
At risk
Days at risk
Avoidable and denied days, with reasons.
Waiting
Advisor referrals open
Physician advisor questions without an answer.
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Use Cases
Where do utilization management software projects start?
First releases we scope, each small enough to prove in one hospital.
01
Admission review queue
Every new admission and observation patient screened the same day.
02
Observation notice tracking
Notices due, delivered and refused, by patient and time.
03
UR committee workspace
Committee cases, determinations and notices out of email.
04
Days at risk reporting
Avoidable and denied days counted daily instead of at month end.
05
Plan concurrent review module
The payer's side of the stay, linked to the hospital's record where both sides agree.
06
Utilization management software for startups
A review platform for a delegated UM vendor serving several clients.
Integrations
Which systems does utilization management software connect to?
The systems a UM build reads from and writes to.
Orders, notes and status
EHR
Admissions and transfers
ADT feed
Licensed or internal
Criteria set
Authorizations
Payer portals and X12 278
Appeals
Denials management
Escalations
Physician advisor service
Notices
Document management
Reporting
Data warehouse
Compliance-First Development Services Backed by Global Standards
We build secure, scalable products designed for privacy, interoperability, and regulatory readiness from day one across every sector we serve.
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, and strict access controls.
Fast Healthcare Interoperability Resources
Enabling standardized health data exchange through standards-based API mappings.
Our Edge
Why Global Leaders Choose Us
We combine deep technical expertise with industry-specific knowledge to deliver solutions that aren't just functional, but transformational.
Enterprise-Grade Security
We implement rigorous security protocols and compliance standards (HIPAA, GDPR, SOC2) across all industrial solutions to protect sensitive data.
High-Performance Scaling
Our architectures are built to handle massive data loads and user bases, keeping performance steady whether you're serving ten or ten million.
Accelerated Time-to-Market
Using our suite of internal tools and proven frameworks, we cut setup work so your first release reaches users sooner.
Embedded AI Integration
Beyond simple wrappers, we build deep-learning integrations and predictive analytics directly into the core of your industry-specific workflows.
Engagement Model
How does a utilization management engagement run?
We start with one hospital and one review step. Timing depends on EHR access and criteria licensing, and we agree a fixed first release on the scoping call.
01
Scoping call
Review types in scope, criteria source, EHR access and payer channels.
02
Workflow mapping
The two-sided table filled in with case management, physician advisors and finance.
03
Fixed-scope first release
Admission review and status decision support live for one hospital.
04
Continued stay and committee
Review scheduling, outlier flags and the committee workspace added.
05
Payer data and support
Authorizations and denials linked in, then support under change control.
Facts and sources
Which rules shape utilization management software?
Short facts we design around, each linked to its primary source.
A hospital's utilization review committee must have two or more practitioners, at least two of them doctors of medicine or osteopathy, and no reviewer may have a direct financial interest in the hospital or have been professionally involved in the patient's care.
Source: 42 CFR 482.30(b) (eCFR)Before deciding that an admission or continued stay is not medically necessary, the UR committee must consult the responsible practitioner, and it must give written notice to the hospital, the patient and the practitioner no later than 2 days after the determination.
Source: 42 CFR 482.30(d) (eCFR)In a hospital paid under the inpatient prospective payment system, the UR committee must review cases it reasonably assumes to be outliers because of an extended length of stay, and must make each periodic review no later than 7 days after the day the UR plan requires.
Source: 42 CFR 482.30(e) (eCFR)For Medicare Part A, an inpatient admission is generally appropriate when the admitting physician expects the patient to need hospital care that crosses two midnights, and the factors behind that expectation must be documented in the medical record.
Source: 42 CFR 412.3(d)(1) (eCFR)A hospital must give a standardized written notice to a Medicare beneficiary who receives observation services as an outpatient for more than 24 hours, no later than 36 hours after observation services begin.
Source: 42 CFR 489.20(y) (eCFR)
Voice of success
We don't just build products; we forge lasting partnerships. See how we've helped industry leaders transform their vision into technical reality.
“I can clearly see how Agnotic has a unique way of handling end-to-end development. They are always active on quick chat and provide support quickly.”
Aaron Phelan
Founder, Benchmark
“Agnotic combines deep technical expertise with strong domain knowledge. They understand the business context, anticipate challenges, and make collaboration smooth and effective.”
John Pasmore
Founder, Latimer
“Agnotic is the best technical team we evaluated. Their engineering excellence made our work dramatically easier and allowed us to stay focused on what matters most for maternal care outcomes. They took full ownership of the technical execution, and we are always happy to continue working together.”
Kim Smith
Founder, My Lauren
Related pages
Related review, authorization and care management software
This page covers hospital utilization review and the shared review record. These pages cover the work around it.
Payer operations software
The payer UM workbench, reviewer routing, appeals and grievances.
Licensed vs internal UM criteria
How criteria handling differs, and what the MA UM committee approves.
Prior authorization automation
FHIR prior authorization APIs, X12 278 and CMS-0057-F.
Care management software
Care plans and transitions after the stay.
AI discharge planning software
Discharge readiness and post-acute placement.
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Frequently Asked Questions
Both, with the hospital side first. The hospital's UR plan, queues, status decisions and committee are built here; the payer's UM workbench and reviewer routing are covered on our payer operations page, and both write to one review history.
No. We integrate the licensed criteria set you hold, or build your internal criteria as versioned rules. How the two differ in the software is on our licensed vs internal UM criteria page.
It captures the admitting physician's expectation and the factors behind it in structured fields next to the order, and flags stays where the documentation is missing. The status decision stays with the physician.
Yes. Committee cases, the consultation with the responsible practitioner, one or two member determinations and the written notices are recorded in one workspace, with the dates the UR plan sets.
The review types in scope, whether criteria are licensed or internal, EHR access, how much payer exchange you need (portals, X12 278 or FHIR prior authorization APIs) and the number of hospitals or clients. We size these on the scoping call instead of using a calculator or price list.
The UM record stores authorization numbers, decisions and approved days. Building the request exchange itself, including CMS-0057-F APIs, is covered on our prior authorization automation page.
AI can summarize the chart and suggest which criteria may apply, with the evidence shown. Determinations stay with licensed reviewers and physicians, and the suggestion and the human decision are both kept in the record.
Industries