Utilization Management / Architecturejilsovereign.com/products/um-attestation/architecture
Architecture

Utilization Management Architecture

Prior auth + concurrent + retrospective review, sealed

Purpose-built attestation for utilization management decisions. Every prior authorization, concurrent review, and retrospective review decision verified against the plan's published criteria, sealed with cryptographic evidence, and re-verifiable by a regulator, an auditor, or a court - with the same evidentiary standard as our settlement integrity pipeline.

3
Decision modes (PA / concurrent / retro)
RADV
Defense-grade evidence
FCA
60-Day Rule documented
Plan-criteria
Auto-mapped per claim

§ 01Business Architecture

AudienceMCO compliance teams, RADV defense leads, in-house plan counsel, state Medicaid integrity programs.
BuyerGeneral Counsel, Chief Compliance Officer, Director of Payment Integrity.
Economic ModelPer-decision flat fee. RADV-defense subscription tier (volume-discounted). No contingency.
PartnersPlan Medical Directors, External MD reviewers, MCO Recovery Audit Contractors.

§ 02Technical Architecture

Decision capture

Plan PA decisions, concurrent reviews, retrospective audits ingested via EDI 278 / FHIR / CSV.

Criteria mapper

Plan's published medical policy + InterQual / MCG criteria mapped to claim line items.

CMS rule lookup

NCD/LCD/MUE/NCCI/Pub 100 - automated citation for each decision.

Verdict Engine

Subset of 175 checks - UM-relevant subset (clinical eligibility, utilization patterns, dual-eligible flags).

CourtChain™ seal

Each decision sealed with criteria-citation + reviewer signature.

Data SourcesCMS NCD/LCD/MUE/NCCI/Pub 100, plan-internal medical policy, InterQual/MCG, NPPES, PECOS, OIG LEIE, RAC findings.

§ 03Process Flow

01
UM decision captured
EDI 278 PA, concurrent-review note, retro-audit finding.
02
Criteria mapped
Auto-cite plan medical policy + CMS NCD/LCD applicable to the claim.
03
Verdict cross-check
JIL runs UM-subset checks against the decision.
04
CourtChain™ seal
Decision + criteria + cross-check sealed. Plan reviewer signs.
05
RADV-ready evidence
Bundle pre-built. CMS RADV auditor receives self-authenticating record.

§ 04Plain English Example

Worked example

Plain English: a 47-hospital DRG cohort flagged for upcoding

Plan ships 47 hospitals' inpatient DRG decisions for FY2024. JIL maps each decision against MS-DRG GROUPER + plan's coverage policy + CMS NCD/LCD. 38% (~1,790 decisions) match upcoding patterns: DRG 470 (uncomplicated) vs DRG 469 (complicated) shifts in cohorts where the population doesn't support the case-mix index. Cohort overage modeled at $1.18B based on PEPPER baselines. Each decision has a sealed CREB™ with the medical policy citation + the upcoding pattern fingerprint. Plan's GC files RADV-defense + qui-tam pre-suit notice.

§ 05Capabilities Summary

Decision modesPrior authorization, concurrent review, retrospective audit
CriteriaPlan medical policy, InterQual/MCG, CMS NCD/LCD/MUE/NCCI/Pub 100
DetectionUpcoding, downcoding, DRG-shift, premature discharge, length-of-stay outliers, dual-eligible misclassification
EvidenceEach decision sealed with criteria citation, plan signature, JIL verdict - RADV-defense ready
ComplianceRADV, FCA 60-Day Rule, HIPAA, plan medical-policy disclosure