Decision Intelligence
Technology OverviewHow It WorksCNLP APIIntelligent Document Processor (IDP)IntelliSync
Use Cases: payors
Prior AuthorizationUM & Clinical ReviewPayment Integrity
Use Cases: Providers
Risk Adjustment & RCMPopulation Health
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Live in Production · Prior Authorization · Payor Solutions
Clinical Intelligence Built for Health Plans at Production Scale.
53% efficiency improvement. Human-in-the-loop with AI assistance for complex cases.
Hindsait is live in production processing prior authorization requests at WPS Health, the Medicare Administrative Contractor for Jurisdictions 5 & 8. For every case where clinical evidence is clear, Hindsait decides. For complex determinations, your clinicians decide with full AI-surfaced context.
Built specifically for health plans, Blues Plans, TPAs, benefit managers, and self-insured employers.
Download Solution Brief →Explore Capabilities
WPSDEPLOYED
Prior Authorization Hindsait is live in production at WPS Health, one of the largest Medicare Administrative Contractors in the country
53%
Efficiency Improvement Documented across payor & provider workflows using the Hindsait platform
3×
Faster PA Decisions Meeting 72-hour CMS mandates with capacity to spare
SOC 2 + HITRUST
CSF Certified & CMS-0057-F Ready Enterprise-grade security meets regulatory compliance
Payor Pain Points, Addressed Directly
The challenges your organization faces right now
Challenge
CMS-0057-F requires accelerated turnaround, real time PA capability, and full audit transparency, on legacy systems not built for it.
Hindsait Solution
CMS-aligned PA workflows with full audit trails, 72-hour standard and expedited decision support, compliant out of the box.
Challenge
Manual UM reviews are slow, inconsistent across reviewers and shifts, and costly per case, yet volume only grows.
Hindsait Solution
MCG, InterQual, CMS LCD/NCD guidelines auto-converted into decision-tree worksheets. ADLs, prior therapies, condition progression auto-matched to criteria.
Challenge
Rising fraud, waste, and abuse exposure with limited real time detection capability, most FWA identified only post-payment.
Hindsait Solution
Claims anomaly detection and clinical pattern analytics flag FWA risks before payment, pre-pay intervention reducing recovery burden.
Challenge
HEDIS, Stars, and CMS quality benchmarks increasingly tied to plan revenue, but gap closure requires member-level visibility most plans lack.
Hindsait Solution
Proactive quality gap analytics with actionable member-level care recommendations, closing gaps before benchmark deadlines, not after.
Challenge
TPAs and self-insured employers lack visibility into utilization trends and plan performance across benefit lines.
Hindsait Solution
Unified analytics dashboards providing utilization, cost, and quality KPIs across benefit lines, giving plan managers the performance visibility to act.
Challenge
ACO and value-based contracts require accurate risk scoring to protect shared savings, manual RAF optimization can't keep pace.
Hindsait Solution
Risk stratification engine combining claims, clinical, and SDOH data for accurate RAF and VBC performance, protecting shared savings.
Four Solution Domains
AI across every payor-critical workflow
01
Utilization Management
Medical Necessity Review Automation
Guidelines auto-converted into structured decision-tree worksheets. ADLs, pain assessments, prior therapies, and condition progression auto-matched to criteria, consistent across every reviewer.
- MCG, InterQual, CMS LCD/NCD auto-converted to decision trees
- Plan-specific criteria and policy integration
- One-keystroke SSU audit navigation
- Consistent determinations across all reviewers and shifts
02
Prior Authorization
AI-Assisted Prior Auth Decision Support
CMS-compliant 72-hour standard and expedited review workflows. payor-specific criteria matching with documentation scoring. PA volume trend analytics and benchmarking.
- CMS-0057-F compliant PA workflows with full audit trail
- 72-hour and expedited review automation
- SSU audit support with one-keystroke record navigation
- PA volume trend analytics and benchmarking
03
Clinical & Fraud Analytics
Payment Integrity & FWA Detection
Payment integrity and claims anomaly detection that identifies fraud, waste, and abuse before payment. Clinical pattern analytics across provider networks.
- Claims anomaly detection pre- and post-payment
- Clinical pattern analytics for FWA identification
- Provider network outlier and pattern analysis
- HEDIS gap reporting and quality measure analytics
04
Member & Risk Management
Risk Stratification & Population Health
Predictive risk stratification for care management. SDOH-aware chronic disease intervention targeting. ACO and value-based contract performance analytics.
- Predictive risk stratification, claims, clinical, and SDOH data
- SDOH-aware chronic disease management targeting
- ACO and VBC contract performance analytics
- Proactive HEDIS and Stars gap closure analytics
How Hindsait Works
From clinical guideline to defensible determination
A four-stage workflow that converts clinical guidelines into consistent, auditable, and CMS-compliant determinations, at any volume, with any payor's specific criteria.
Step 01
Ingest Clinical Guidelines
Hindsait ingests MCG, InterQual, CMS LCDs/NCDs, or plan-specific policies as the authoritative source for review criteria, keeping your AI aligned to the exact standards your plans operate under.
MCG · InterQual · CMS LCD/NCD · Plan-Specific
Step 02
Auto-Convert into Decision-Tree Worksheets
Guidelines are automatically converted into structured decision-tree worksheets, questions, branching logic, and criteria derived directly from the guideline content. No manual authoring. No version drift.
Automated Conversion · No Manual Authoring · Always Current
Step 03
Apply Decision Tree to Medical Records
The decision tree is applied to each medical record under review. ADLs, pain assessments, prior therapies, and longitudinal condition progression are extracted and mapped to criteria automatically.
Clinical NLP · ADL Extraction · Condition Progression Mapping
Step 04
Faster Determinations & One-Keystroke Audit Navigation
Reviewers work from pre-populated, policy-aligned worksheets for consistent, defensible determinations. The Hindsait Audit Platform brings users directly to the most relevant record information with a single keystroke, accelerating SSU audits, appeals, and CMS compliance reviews.
One-Keystroke Navigation · Pre-Populated Worksheets · Full Audit Trail
Measurable Business Impact
The outcomes health plans and payors measure
↓UM Review CostAutomated medical necessity review shifts reviewer time from document search to clinical judgment
3×Auth TurnaroundFaster prior auth decisions, meeting 72-hour CMS mandates with capacity to spare
↑ StarsHEDIS & Stars PerformanceProactive member-level gap closure improves plan ratings, protecting Stars revenue bonuses
↓ FWAFraud, Waste & AbuseClaims anomaly detection flags FWA risks pre-payment, reducing exposure and recovery burden
Payor Resources
Choose Your Download
The Payor Solution Brief requires a short form. The White Paper is open access — download starts immediately.
Payor Solution BriefResponsible AI White Paper
The full Hindsait payor Solution Brief, capability breakdown, client outcomes, and the WPS Health Solutions case study showing a 30% efficiency gain in medical review processing.
Payor Solution Brief
Complete the form to unlock the full PDF
Download the Payor Solution Brief
Detailed capabilities, client outcomes, and the WPS Health Solutions case study. Your download starts immediately on submission.
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Published in partnership with WPS Health Solutions
WPS Health Solutions · Open Access
Download the White Paper
Responsible AI governance, CMS-aligned automation strategy, and documented 53% efficiency outcomes from the WPS Health Solutions production deployment.
53% PA efficiency improvement — documented production outcomes
Responsible AI governance framework for health plan operations
CMS-aligned prior authorization automation strategy
WPS Health Solutions Medicare Administrative Contractor case study
Ready to see Hindsait in your UM workflow?
Most health plan clients are in production within 6 to 8 weeks. See a live demo with your own clinical guidelines and document types.
Request a DemoDownload Solution Brief White Paper
This Is What Healthcare AI Should Look Like.
Production-deployed with WPS Health. Audit-ready by design. Proven to reduce prior authorization review time by 53%. Hindsait turns clinical records into decision-ready intelligence for prior authorization, clinical review, and payment integrity.
Gartner® recognized, built on 12 years of healthcare-specific clinical NLP, and shaped by 100M+ medical records processed across real clinical workflows.
Request a Demo →See How It Works
53%Prior Auth (PA) EfficiencyDocumented across real PA deployments
100M+Medical Records ProcessedSince 2013, across real clinical workflows
12 yrsHealthcare-Specific AI R&DCNLP trained on clinical data since 2013
3×Faster PA DecisionsTurnaround time across deployed health plans
6–8 wksWeeks to Live DeploymentBuilt to complement, not replace existing systems
PALIVE
Live in ProductionProduction-deployed prior authorization (PA) workflows with audit-ready clinical oversight
Gartner®
2026 Representative VendorGartner Market Guide for Intelligent Prior Authorization, inaugural edition
HITRUST CSFCertified InfrastructureHIPAA + SOC 2 · Enterprise-grade PHI protection at every layer
WPS Health SolutionsLive Production ClientMedicare Administrative Contractor · Jurisdictions 5 & 8
Florida BlueStrategic InvestorGuideWell · One of the largest Blues Plans in the country
Why Hindsait Is Different
Clinical AI that has earned its place in production.
Production deployment in prior authorization requires evidence, controls, and auditability—not marketing claims. Automated evidence matching for clinically clear cases.
With Florida Blue among our strategic backers and twelve years of healthcare-specific CNLP training, Hindsait brings accumulated clinical intelligence built through years of real clinical data, deployment, and refinement.
01
Proven at production scale
100M+ records processed. Live in production at WPS Health, a Medicare Administrative Contractor, processing real PA workflows. Already operating in live authorization workflows.
02
Human-in-the-loop where it matters
Automated evidence matching for clinically clear cases. Clinician review for complex determinations. Live in 6–8 weeks, built to complement, not replace your existing UM, PA, EHR, or claims systems.
03
53% PA efficiency. Verified.
A documented outcome across real deployments, not a modeled projection. Measured across prior authorization and clinical audit workflows, the Hindsait platform delivered 30% time savings.
04
Flexible Deployment. Your Environment, Your Terms.
Deploy on-premises or on cloud — GCP, AWS, or Azure — based on your data governance and security requirements. Same platform, same clinical intelligence, same audit trail. No vendor lock-in. No forced migration.
Production Deployment · Prior Authorization
53%
Efficiency improvement across prior authorization and clinical review workflows
Live in production at WPS Health, a Medicare Administrative Contractor for Jurisdictions 5 & 8. Automated evidence matching where clinical criteria are conclusively met. Clinicians in the loop for complex determinations.
"
Having the Hindsait team deeply integrated with our operational SME's, we were not only able to cut our medical review time by over 50%, we also developed new and novel additional uses and custom capabilities with the Hindsait platform to add greater value to our organization, staff, and customers.
BJ
Brian Janssen
Chief Information Officer, WPS Health Solutions
Download the White Paper →
How Hindsait Works
Clinical intelligence, built in layers.
Every Hindsait decision starts with the same foundation, structured clinical intelligence extracted from the documents you already have. One base layer. Every use case above it.
Use Case Layer, Powered by IDP Clinical Intelligence
Prior Authorization
PA decision support. Criteria-matched. Audit-ready. Human-in-the-loop for complex cases.
Production Deployed3× Faster
UM & Clinical Review
MCG, InterQual, LCD/NCD criteria applied consistently across every concurrent and retrospective review.
Guideline-Aligned30% Time Savings
Payment Integrity
Claims anomaly detection, post-payment clinical review, FWA pattern analysis across your full population.
FWA DetectionPopulation Scale
Risk Adjustment & HCC
HCC coding gap identification, RAF score optimization, and RADV-ready audit trail for ACOs and health plans.
RAF OptimizedRADV-Ready
Revenue Cycle & Coding
Automated ICD-10 to HCC crosswalk, AI-assisted coding with human review, and provider prior authorization.
HCC CrosswalkAudit-Proof
Population Health & More
HEDIS, Stars, SDOH analytics, quality oversight, ACO performance, pharma market access, and RWE.
HEDIS / StarsQuality & Pharma
Structured clinical intelligence feeds every use case above
Foundation Layer
Hindsait IDP
Intelligent Document Processor
One foundation layer, every use case above it. IntelliSync, our automated policy intellgence layer, continuously monitors CMS, payor policies, and clinical guidelines, so every decision the pipeline produces is always aligned to current criteria, without manual updates.
Explore IDP →
Ingest
Any source
any format
Clinical NLP
Context-aware
understanding
Extract & Summarize
Key facts
GenAI summary
Score & Route
Evidence strength
smart routing
Deliver
Real-time API
audit trail
95%
Extraction
Accuracy
<30s
Per
Document
50+
Clinical
Entity Types
Who We Serve
Built for every side of the clinical decision
One platform. Three distinct solution sets, each designed for the workflows, pain points, and buyers that define that segment of healthcare.
Payor Solutions
Health Plans & Payors
Automate PA, UM, clinical audit, and payment integrity while meeting CMS-0057-F mandates and HEDIS benchmarks, without adding headcount.
- CMS-0057-F compliant PA automation
- MCG, InterQual, LCD/NCD decision trees
- Payment integrity & FWA detection
- HEDIS & Stars gap analytics
Explore Payor Solutions →
Pharma Solutions
Pharma & Life Sciences
Accelerate specialty drug access, decode payor policies , and extract real-world clinical evidence to power market access strategy.
- Specialty drug PA automation
- payor policy monitoring, 100s of plans
- Real-world evidence extraction
- HEOR & outcomes analytics
Explore Pharma Solutions →
Provider Solutions
Providers & Health Systems
Reduce claim denials, cut documentation burden by 40%, and optimize ACO and value-based care performance from one clinical intelligence layer.
- AI documentation, 40% burden reduction
- Denial risk scoring pre-submission
- MIPS, Stars, HEDIS gap analytics
- Predictive readmission alerts
Explore Provider Solutions →
Results & Recognition
Trusted by healthcare's most demanding organizations
Magellan Health](https://www.magellanhealth.com/) WPS Health Solutions](https://www.wpshealth.com/) NY Blood Center](https://www.nybc.org/) GuideWell Innovation](https://guidewellinnovation.com/) Hackensack UMC](https://hackensackmeridianhealth.org/en/locations/hackensack-university-medical-center)
"
Hindsait's technology and creative approach have opened new doors in how we use data to manage our business.
Tina Blasi
CEO, NIA / Magellan
"
Hindsait’s proven AI technology and differentiated platform, coupled with its seasoned executive team, set it apart.
Ateet Adhikari
Vice President, Healthbox
"
We worked with Hindsait to fine-tune predictive analytics that would enhance our efficiency without compromising quality.
Laurel Douty
COO, Magellan Healthcare
"
Hindsait's ability to identify meaningful clinical insights creates a better pathway for care delivery across our entire network.
Renee Finley
Head of Innovation, GuideWell
"
Having the Hindsait team deeply integrated with our operational SME's, we were not only able to cut our medical review time by over 50%, we also developed new and novel additional uses and custom capabilities with the Hindsait platform to add greater value to our organization, staff, and customers.
Brian Janssen
Chief Information Officer, WPS Health Solutions
Gartner 2026 Market Guide](https://www.gartner.com/en/documents/7430962) Forbes Healthcare AI Recognition](https://www.forbes.com/councils/forbesbusinesscouncil/2023/11/28/how-ai-is-transforming-healthcare-risk-adjustment/) Gartner Cool Vendor 2017](http://www.prnewswire.com/news-releases/hindsait-inc-named-a-cool-vendor-in-ai-in-healthcare-by-gartner-300465248.html) HITRUST CSF Certified](https://www.newswire.com/news/hindsait-achieves-hitrust-csf-certification-to-manage-risk-improve-21141491) Frost & Sullivan Best Practices Award](http://www.prnewswire.com/news-releases/frost--sullivan-applauds-hindsait-for-pioneering-healthcare-centric-artificial-intelligence-systems-300280393.html)
Proven Outcomes
Efficiency without compromising quality
Every metric to the right comes from a real Hindsait client deployment, not modeled projections. Healthcare Decision Intelligence delivers measurable ROI within the first quarter of deployment.
Built for the buyer who counts cost per review. Hindsait clients report measurable FTE reallocation, faster turnaround, and reduced rework, translating directly to lower administrative cost per clinical decision.
3×
Faster PA Processing
Turnaround time across deployed health plans
+30%
Medical Review Efficiency
WPS Health Solutions deployment
35%
Unnecessary Cost Reduction
Evidence-based AI applied to utilization review
53%
Prior Auth (PA) Efficiency
Documented across real PA deployments
+24%
First-Pass PA Approval Rate
payor-aligned submissions, first time
98%
Decision Consistency
Uniform determinations across every reviewer
News & Recognition