GALAXY UM - PAYER UTILIZATION MANAGEMENT

Payer Utilization Management for Faster Decisions and Better Member Outcomes

Agentic AI that automates end-to-end utilization management to reduce manual work, lower costs, and help members get the right care faster across all lines of business, guided by evidence-based criteria.

See it in Action
See it in Action
Download Overview
Download Overview
Innovaccer is trusted to deliver value at scale
Built to help health plans make faster, more transparent,
and more defensible utilization management decisions.
1
Only auto-approve. Never auto-deny.
Requests that clearly meet criteria can be approved in real time. Every other case is routed to a qualified clinician for review.
2
Every determination is explainable.
Clinical rationale, policy support, and a clear audit trail across determinations.
3
Connected platform, not a point solution
More than a stand-alone UM tool, Galaxy UM extends the connected platform behind Galaxy into UM.
4
More context for every determination.
Clinical data, claims history, payer policy, and authorization context are unified in one model to support more informed review.
5
Agentic AI,
not a rules engine
Specialized agents automate the UM workflow end to end, with human oversight at critical decision points.
From intake to determination. 

Streamlined and compliant.
Agentic AI helps orchestrate the full utilization management lifecycle on a connected payer platform, so your clinical team can focus on the decisions that require their judgment.
INTAKE & DATA EXTRACTION
Every request is captured and normalized across channels
FHIR API, provider portal, EDI X12 278, and fax
Member eligibility verified at intake, with immediate tracking
OCR and AI extract clinical evidence from unstructured documents
MEDICAL NECESSITY EVALUATION
Qualifying requests are approved in real time. 
All others are escalated, never auto-denied.
AI evaluates against plan-specific medical necessity criteria
Configurable by CPT code, line of business, and gold-card programs
Non-qualifying cases are routed with an AI-prepared clinical summary, helping reviewers move faster and members access care sooner.
CLINICAL REVIEW WORKFLOW
Reviewers decide, not search. Every case is pre-analyzed, deadline-tracked, and aligned to timely member care.
AI-prepared summary, with evidence extracted and criteria gaps identified
Worklist prioritized by urgency and review timeline
Physician peer review is enforced for all adverse determinations
PROVIDER COMMUNICATION
Every decision reaches providers quickly and clearly.
Determination letters are auto-generated and sent via portal or fax
Providers are notified quickly of approvals, denials, and additional information requests
Provider portal gives real-time status visibility, reducing inbound inquiry volume
Site-of-care guidance included with authorization responses
COMPLIANCE, ANALYTICS, AND REPORTING
Full visibility into performance, compliance, and turnaround readiness.
Real-time dashboard across approval rates, turnaround times, cost per PA, and denial trends
Automated turnaround tracking across all lines of business
Denial reasons documented with appeal rights included
Surfaces avoidable utilization trends, including unnecessary imaging and procedures
Measurable Impact Across Cost, Speed, and Quality
Results that help health plans improve performance while supporting better member outcomes.
Up to 70%
First-review decisions in real-time
Medicare Advantage Plans
Up to 98%
Lower transaction cost per authorization
From $3.52 manually toward ~$0.05 electronically
5-11%
Medical cost reduction potential
Through appropriate utilization management
12-25%
UM administrative savings
Reduction in operational overhead
98%+
Clinical guidelines adherence
Targeted vs ~72% industry average
$15M-$4B+
Potential annual savings
From small regional plans to large national payers
Based on internal benchmarks and published industry studies.
The Foundation for Enterprise Utilization Management
As part of the Galaxy suite for payers, Galaxy UM brings the same connected platform foundation to utilization management, helping health plans automate intake, support compliant review, and scale with confidence.

Unified UM Context

Clinical data, claims history, payer policy, and authorization context unified in one governed source.

AI Agent Enablement

Deploy UM agents with full oversight to automate intake, evidence extraction, policy evaluation, and reporting.

Configurable
Policy Engine

Plan-specific medical necessity criteria by CPT code, line of business, and exception rules, updated without engineering.

Built-In Intelligence

Criteria gaps, supporting evidence, deadlines, and next-best actions surfaced directly in reviewer workflows.

Interoperability by design

HL7 FHIR R4, Da Vinci Prior Auth, X12 278, and CMS-0057-F-aligned workflows.

Leading Healthcare Organizations 

Choose Innovaccer

“Our partnership with Pharmacy Quality Solutions enables us to strengthen relationships with the city’s pharmacies—the cornerstones of community care—while continuing to redefine the scope and reach of healthcare access for members at every touchpoint.”
Abdou Bah
Chief Health Equity Officer of  EmblemHealth

“IInNote saves me 30 minutes a day that I would have otherwise spent chasing down information.”

Scott Maron, MD
President, Atlantic Health ACO
see full case study
$1M
in potential incentive payments
10%
improvement in coding gap closure rate
30
minutes a day saved per provider
“By making data more accessible and accurate, and using AI in practical ways, we can actually solve the day-to-day
Nick Moriello
President of Highmark Blue Cross Blue Shield Delaware
Built to support compliance, transparency, and audit readiness.
HIPAA compliant, HITRUST certified, SOC 2 Type II, and NCQA-certified
Designed to support CMS-0057-F requirements and URAC audit readiness
Explainable AI with human oversight at every critical step
Clear rationale, policy support, and audit trails across determinations
Modernize utilization management with Galaxy UM
Connected workflows, stronger decision support, and faster access to appropriate care for members.
Request a demo
Request a demo

Frequently Asked Questions

Frequently Asked Question

What is Galaxy UM?

Galaxy UM is a payer utilization management solution that uses agentic AI to automate end-to-end UM workflows.

What workflows does Galaxy UM support?

Galaxy UM supports prior authorization, concurrent review, and retrospective review across all lines of business.

Does Galaxy UM ever auto-deny requests?

No. It only auto-approves qualifying requests. All other cases go to a qualified clinician for review.

How does Galaxy UM support explainable and compliant decisions?

Galaxy UM documents clinical rationale, policy citation, and a complete audit trail for every determination, and is designed to support CMS-0057-F-aligned workflows.
Innovaccer © 2026

Terms

Privacy