Evals for Humata Health

Payer and plan-level auth requirement lookup

Determining auth-required vs. not-required for a service against the correct plan, not just the payer brand.

AI-driven clinical bundling

Grouping related services into a single correct authorization request rather than fragmenting or over-bundling.

CPT mismatch detection

Flagging divergence between ordered, authorized, and performed procedure codes.

Specialty drug and infusion requirement handling

Requirement determination for drug/infusion requests, including site-of-care and buy-and-bill vs. pharmacy benefit distinctions.

Policy matching to the request at hand

Selecting the governing policy version for the payer, plan, service, and date of service.

Criteria extraction and structuring

Turning prose policy documents into discrete, checkable medical necessity criteria.

Citation and provenance transparency

Attributing every asserted requirement to a locatable source passage instead of paraphrase or inference.

Policy currency and change management

Behavior when a policy is updated, superseded, or unavailable for the requested plan.

Documentation-to-criteria alignment

Identifying which record elements satisfy which criteria and which criteria remain unmet.

Smart attestation answering

Answering payer questionnaire and attestation items from the record without asserting unsupported facts.

Gap identification and provider query

Naming the specific missing documentation needed rather than submitting an incomplete packet.

Exception routing to human review

Escalating low-confidence or ambiguous cases instead of auto-advancing them.

Submission packet assembly and channel selection

Producing a complete, correctly formatted submission over the available payer channel.

Automated statusing and determination capture

Polling and interpreting payer status, including pended, partial, and additional-information-requested states.

Post-auth drift and validity monitoring

Detecting expiration, unit exhaustion, or scope changes after approval.

Denial and peer-to-peer support

Surfacing denial reason codes and the material needed for appeal or peer-to-peer.

End-to-end audit trail completeness

Reconstructing who or what decided each step, on which policy version, with which evidence.

Performance analytics by payer, staff, and service line

Accurate aggregation and bottleneck attribution across dashboards.

AI-driven audit of automated decisions

Retrospective checks that touchless determinations matched policy.

Intelligent gold-carding eligibility

Identifying providers or services that qualify for reduced authorization requirements.

Zero-integration provider portal onboarding

First-auth workflow for an independent practice with no EHR connection, replacing phone/fax/mail.

Payer-side compliant authorization workflow

Determination workflows that meet the payer's own compliance and transparency obligations.

Pharmacy and specialty drug workflow

Segment-specific intake and renewal paths for infusions and specialty drugs.

Intake and support routing

Correct handling of contact form interest categories and directing WISeR / Oklahoma provider questions to the right support channel.