Prior Auth & UM
The CMS Final Rule + NCQA UM standards + state AI-in-claims laws all demand the same evidence: cited medical policy + replayable trail + bias score per decision. Sovereign Matrix ships this out-of-box, HIPAA-defensible by default.
PHI never reaches a third-party LLM. Layer-3 PII scanner runs before any model call. Every decision produces a signed receipt that survives a HIPAA audit.
Reveal the AI's verdict (approve / deny / pend) to a state regulator without revealing the rest of the patient file. Merkle-proof inclusion proofs make this cryptographic — not policy-based.
Every decision cites the specific medical-policy section + clinical guideline. Hallucination detector ensures every cited reference exists. Bias auditor flags decisions skewed by demographics.
SOC 2 indicator collector tracks decision pass-rate, MTTR on denials, drift on policy updates. Quarterly attestation letter signed by Medical Director.
When a denial is overturned on appeal, the agent drafts the response letter citing the original clinical evidence + updated guidelines. Multi-party attestation: UM nurse + Medical Director co-sign.
"Triage the morning prior-auth queue for the new orthopedic codes."
Auto-decision rate 60%+ with audit trail. UM nurse review time -70%.
"Draft an appeal-response letter for the denied surgery case."
Appeal letter + cited evidence map + signed receipt. SLA compliance -50% turnaround.
"Prep the NCQA UM accreditation evidence packet."
NCQA evidence packet delivered to the surveyor before they ask.
Selective disclosure (Cook 12) is the unlock. A state attorney general asks “show me how you decided this denial” — Sovereign reveals the verdict + cited policy section, cryptographically sealed, without exposing the rest of the member file. That’s the audit posture HIPAA + 42 CFR Part 2 were waiting for.
Schedule a procurement deep-dive