A clinical appropriateness engine that gives your UM team auditable, citation-bound determinations in seconds — without ever overriding the requesting clinician's encounter type. Built to reduce reviewer time, defend denials on appeal, and keep you out of regulatory trouble.
Every Meets / Does Not Meet determination is traced condition-by-condition to a specific Arc Care criterion ID. There is no black-box score, no proprietary risk model a state regulator or DOL auditor can't unpack. When a provider appeals, your nurse reviewer hands them the exact criteria that were and weren't met — not a number. That's the difference between a defensible denial and a reversed one.
Arc Care pre-adjudicates the structured part of the chart — inclusion criteria, exclusion criteria, severity scoring, LOC recommendation — so your nurse reviewer opens the case with the determination already drafted and the supporting evidence already cited. Clean cases auto-clear. Pending cases route to a human with the missing data points flagged. Reviewers spend their time on the 20% that needs judgment, not the 80% that's mechanical.
No. Arc Care is deliberately conservative on the two things that get payers sued. It never flips the encounter lane — if the clinician submitted Outpatient, the determination is Outpatient. If scoring suggests higher acuity, the engine emits an advisory for the human reviewer; it does not auto-convert to Inpatient. And it's comfortable saying "Pending." When data is missing, the engine routes to a human instead of guessing. You don't get a wrong answer dressed up as a confident one.
Most engines tell you what — Arc Care tells you which criterion and why, every time.
Appropriateness (yes/no), Severity (how sick — advisory), and Lane (clinician-submitted, immutable) are decided independently and audited independently. Most competitors collapse these into a single opaque output — exactly what regulators are starting to push back on.
Every threshold and criterion has an owner and a version. When CMS updates a coverage rule or your medical policy committee revises a guideline, the change is a tracked diff — not a vendor black-box update you can't inspect.
Arc Care Appropriateness Criteria is a clinical decision support layer purpose-built for the realities of utilization management — Medicare Advantage, Medicaid managed care, commercial, and workers' compensation. Every determination is grounded in published clinical evidence, mapped to coverage policy, and structured to withstand provider appeals, IRO review, and CMS or state DOI audit.
Your medical directors stay accountable. Your nurse reviewers move faster. Your denials hold up. Your medical loss ratio gets the relief it needs — without the regulatory exposure.
Pilot the appropriateness engine on your live workflow. Citation-bound determinations, SLA-backed turnaround.
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