Live Agent Demo

Concurrent Review & UM Automation

Watch an agent perform real-time concurrent review of inpatient stays — applying InterQual criteria at each LOS milestone, detecting potential denials before they occur, and drafting peer-to-peer briefs automatically. Zero manual routing.

Agentic AI InterQual Criteria Simulated

Domain Utilization Management · Concurrent Review

Steps 6

Runtime <90 sec

AI Type Agentic + Classical

Active Inpatient Census

Scanning

agent > load_inpatient_census(plan="SilverCare MA", date="2025-03-14", include_los_flags=true)

Member ID	Name	Age	Admit	DRG	Facility	LOS	Limit	Status
`MA-00287`	Nguyen, T.	72	Mar 10	DRG 291 (CHF)	Memorial Medical Ctr	Day 4	Day 4 ⚠️	Review Due
`MA-00512`	Jackson, M.	58	Mar 11	DRG 460 (Hip Replacement)	Summit Ortho Hospital	Day 3	Day 5	On Track
`MA-00198`	Castillo, E.	79	Mar 12	DRG 194 (Simple Pneumonia)	Riverside General	Day 2	Day 3 ⚠️	Review Due
`MA-00334`	Adams, J.	69	Mar 8	DRG 291 (CHF)	Memorial Medical Ctr	Day 6	Day 4 🔴	Extended — Denial Risk
`MA-00445`	Williams, R.	67	Mar 13	DRG 454 (Spinal Fusion)	BluePeak Spine Ctr	Day 1	Day 3	On Track
`MA-00421`	Park, S.	65	Mar 14	DRG 392 (Esophagitis)	Northside Medical	Day 0	Day 2	Admitted Today

6 active inpatient stays · 2 review due today · 1 beyond LOS limit · $0 denied (proactive management)

InterQual Criteria Assessment — Nguyen, T.

Evaluating

agent > assess_continued_stay(member_id="MA-00287", drg="DRG-291", review_day=4, guidelines="InterQual-IP-CHF-2025")

Concurrent Review — MA-00287 Nguyen, T. | DRG 291 | Day 4 of 4

InterQual Criteria — Continued Stay (CHF)

Day 4 Review

✅

IV diuresis still active

Furosemide 80mg IV BID, last dose 6am today

YES

✅

Daily weights documented with >1kg variance

2.3kg over yesterday — fluid retention persists

YES

✅

Fluid overload symptoms persist

Bilateral crackles, peripheral edema +2

YES

⚠️

BNP trending down

BNP 312→280 — improving but not at discharge threshold <150

PARTIALLY

✅

Dietary/fluid restriction education not yet complete

Education scheduled for today — RN documentation pending

YES

✅

Transition planning not finalized

SNF evaluation pending — Sunrise Skilled Care contacted

YES

✅ Extension Justified — 5/6 Criteria Met

Approve 2 additional days (Days 5–6). Continued inpatient stay medically necessary — BNP improving but above discharge threshold, IV diuresis ongoing, SNF placement pending.

Clinical reviewer note auto-drafted: “Continued inpatient stay medically necessary — BNP improving but above discharge threshold, IV diuresis ongoing, SNF placement pending.” Sent to Memorial Medical Ctr utilization department.

Denial Risk Intervention — Adams, J.

Intervening

agent > intervene_denial_risk(member_id="MA-00334", days_exceeded=2, submit_extension=true, generate_justification=true)

Adams, J. (MA-00334) | DRG 291 (CHF) | Memorial Medical Ctr

Day 6 — Auth limit: Day 4

Denial Risk

🔴 DENIAL RISK ALERT — 2 days beyond authorized LOS without extension approval

Clinical Situation

BNP 420 pg/mL (elevated)

Creatinine 2.4 (CKD exacerbation)

IV Diuresis Ongoing

Attending “Unstable for discharge”

Agent Actions Taken

✅

Extension request submitted to payer UR desk

3:47 AM today — automated overnight submission

✅

Clinical justification letter drafted and attached

Citing BNP trajectory, CKD exacerbation, cardiologist instability documentation

✅

Attending cardiologist notified (Dr. Reyes)

Requested documentation of instability in Day 6 progress note

✅

Day 5 + Day 6 retroactive extension request pending

Response expected within 4 hours

Risk if not resolved $18,400 retroactive denial

Extension approval probability 89%

AI decision — human override available

Human Override — Adams, J. (MA-00334) · DRG 291 (CHF) · Memorial Medical Ctr

Select Decision

Approve 2-Day Extension

Deny Extension

Request Additional Clinical Docs

Escalate to Medical Director

Override Reasoning

Agent re-evaluating with human override…

Override will be logged in the audit trail with your identity and timestamp.

Discharge Planning Integration

Coordinating

agent > coordinate_discharge_plans(census_date="2025-03-14", members=6, integrate_post_acute=true)

Member	Discharge Status	Target Date	Post-Acute Plan	Barriers
Nguyen, T.	In Progress	Mar 16	SNF — Sunrise Skilled Care	SNF bed availability
Jackson, M.	Scheduled	Mar 15	Home + PT (3x/week)	None — ready
Castillo, E.	Evaluating	Mar 14	Home w/ home health	Transportation for follow-up
Adams, J.	Pending Stability	Mar 16+	Cardiac Rehab + SNF eval	Clinical instability
Williams, R.	Early Planning	Mar 16	Home w/ wound care	None
Park, S.	Too Early	Mar 16	TBD	—

Auto-Actions Executed

📋

SNF referral submitted for Nguyen

Sunrise Skilled Care — 2.3 mi from residence · bed check requested

🏠

Home health order drafted for Castillo

RN visits 3x/week · transportation assistance referral initiated

🏋

PT referral submitted for Jackson

Outpatient PT 3x/week at Summit Rehabilitation · starts Mar 17

P2P Brief Auto-Generation

Generating

agent > prestage_p2p_brief(member_id="MA-00334", trigger="extension_denial", guidelines=["ACC-AHA-2022","CMS-MN"])

Peer-to-Peer Escalation Brief — Pre-staged

Member Adams, J. (MA-00334)

DRG 291 — CHF

Facility Memorial Medical Ctr

Prepared in advance Yes — denial risk flag

Status Pre-staged

Clinical Argument — 4 Key Points

BNP remained at 420 pg/mL on Day 6 (admission BNP: 780) — still >3x upper normal limit. Discharge threshold of <150 not met.

Creatinine elevated to 2.4 mg/dL — new CKD exacerbation complicating diuresis titration. Nephrology consulted Day 5.

Attending cardiologist (Dr. A. Reyes, Memorial Medical Ctr) documented patient “hemodynamically unstable for safe discharge” in Day 6 progress note.

SNF placement evaluation ongoing — premature discharge without post-acute plan risks 30-day readmission.

Literature Cited

ACC/AHA Heart Failure Guidelines 2022 CMS MA Medical Necessity Standards

P2P brief pre-staged. Clinical argument built from 6 days of progress notes, lab trends, and attending documentation. Ready to transmit within minutes of any denial.

Daily UM Summary & Cost Avoidance

Complete ✓

6 Members reviewed

2 Reviews completed

1 Extensions approved (1 pending)

1 P2P briefs generated

Cost Avoidance Estimate

Intervention	Member	Amount
Proactive extension — denial risk mitigated	Adams, J.	$18,400
Timely extension — retrospective denial avoided	Nguyen, T.	$12,200

Total estimated cost avoidance today $30,600

LOS Tracking: No unnecessary LOS days detected across 5 of 6 members. Adams extended beyond auth — active intervention underway.

Compliance: All concurrent reviews completed within CMS 24-hour response standard. Zero escalation delays.

Time: Manual UM review estimated: 4.5 hrs/day. Agent completed in 52 seconds.

View All Demos

NestedLoop UM Agent

Ready — loading inpatient census

Current Tasks

Concurrent Review & UM The UM agent monitors active inpatient stays in real-time, applies InterQual continued-stay criteria at each LOS milestone, detects denial risk before it materializes, and pre-stages P2P briefs so escalation response time is measured in minutes — not days.

About this Demo All data is synthetic. Member IDs, names, provider names, LOS data, and dollar amounts are fictional. The agent logic, InterQual assessment engine, denial intervention, and P2P generation capabilities reflect real NestedLoop deployment patterns.

Disclaimer: This is an interactive demonstration using simulated data and pre-scripted AI responses. No real patient, member, or provider data is used. All values are fictional and for illustrative purposes only. Real deployments include full HIPAA compliance, SOC 2 audit controls, CMS regulatory adherence, and clinical review oversight.

Proprietary assets of NestedLoop LLC. Reproduction or re-use with explicit consent and authorization from NestedLoop LLC only.