Utilization Management Demo Steps
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ARKA Clinical Decision Support is designed to meet all four criteria for Non-Device CDS under FD&C Act §520(o)(1)(E) and FDA's January 2026 final guidance on Clinical Decision Support Software. Recommendations support, not replace, the clinician's judgment. Every recommendation is anchored in a published guideline or peer-reviewed source, with the basis available for independent review. INS emphasizes prior authorization, coverage, and cost transparency workflows.
This recommendation is intended to support, not replace, clinical judgment. It is generated by ARKA, software designed to meet the four criteria for Non-Device Clinical Decision Support under FD&C Act §520(o)(1)(E) and FDA's final guidance on Clinical Decision Support Software (January 2026). The clinician is responsible for the final decision.
ARKA-INS
The payer-side demo: run the same appropriateness math clinicians see, streamline prior auth and appeals, and reduce denials — Non-Device CDS, CMS-0057-F ready.
The same engine on the payer side — CMS-0057-F Da Vinci PAS, shipping today.
Which door is yours?
Live counters — 60m window
requests / min
emitted / min
cards / min
breaches / min
tier rate %
acceptance %
This is the payer-side model. The risk-buyer model is at /roi.
Basics
35%
12%
86%
55%
60%
35%
25%
50%
Pricing (PMPM)
Modeled · conservative
Modeled, conservative estimate. ARKA is Non-Device CDS — figures are decision-support economics, not a guarantee of outcomes. Aggressive case ≈ 1.5× the conservative figures.
Modeled at ARKA Pro $0.45 PMPM × 300,000 lives
$4.45M / yr
Net of ARKA cost: $2.83M
Denial prevention
$4.08M
Documents medical necessity at the point of order, so avoidable denials never happen.
Rework labor avoided
$86K
Fewer denials means fewer appeals your staff has to work.
Prior-auth admin saved
$286K
Automates the ~24-min manual PA your team does today.
Effective denial rate
min(45%, 12% base + 35% MA × 4 pts = 12% + 1.4%)
= 13.4%
Avoidable denied orders
120,000 orders × 13.4% effective denial × 86% avoidable
= 13,829 orders
Revenue at risk today
13,829 avoidable denials × 55% never reworked × $1,180
= $8.97M
Prevented denials
13,829 avoidable denials × 25% reduction
= 3,457 orders
Denial recovery (Lever 1)
3,457 prevented × $1,180
= $4.08M
Rework avoided (Lever 2)
3,457 prevented × $25 rework cost
= $86K
Automated prior authorizations
120,000 orders × 60% require PA × 50% automated
= 36,000 PAs
Admin labor saved (Lever 3)
36,000 PAs × (14 min ÷ 60) × $34/hr
= $286K
Contribution per study
$1,180 reimbursement × 35% margin
= $413
Gross annual benefit
$4.08M + $86K + $286K
= $4.45M
ARKA annual cost
$0 PMPM × 300,000 lives × 12 mo
= $1.62M
Net annual benefit
$4.45M gross − $1.62M ARKA cost
= $2.83M
First-year ROI multiple
$4.45M ÷ $1.62M
= 2.7×
Payback period
$1.62M ÷ ($4.45M ÷ 12 mo)
= 4.4 months
Sources
Modeled, conservative estimate. ARKA is Non-Device CDS — figures are decision-support economics, not a guarantee of outcomes. Aggressive case ≈ 1.5× the conservative figures.
RBM workflow benefits. ARKA-INS guides prior authorization through evidence-based RBM (Radiology Benefit Management) criteria. You get pre-submission analysis, documentation gap identification, and criteria mapping so submissions are complete before they reach the payer.
Prior authorization assistance. The demo includes denial risk scoring, AI-generated clinical justification, and appeal letter generation. For high-risk cases you see mitigation steps; for denied cases you can generate a structured appeal with cited guidelines.
Connection to clinical and educational insights. ARKA-INS aligns with ARKA-CLIN (imaging appropriateness) and ARKA-SIM (education). Appropriate ordering and strong documentation improve approval rates; learning from denial patterns and criteria strengthens future submissions.
AIIE (ARKA Imaging Intelligence Engine) applies the same clinical appropriateness methodology used by ordering physicians. This creates alignment between clinical and payer perspectives—evidence-based, transparent, and auditable.
Streamlining utilization management with transparent, evidence-based decisioning.
Automated pre-screening handles routine cases
Same evidence-based criteria across all reviewers
Transparent reasoning reduces provider disputes
Full audit trail and documentation
Regulatory standing
WISeR
In forceCMS's Wasteful and Inappropriate Service Reduction model pairs AI with licensed clinical review on the denial path for select services.
1 January 2026
Evidence →CMS-0057-F
In forceImpacted payers publish machine-executable prior-authorisation rules; ARKA executes whichever rules apply rather than authoring its own.
8 February 2024
Evidence →Imaging AUC
RescindedThe programme ARKA was originally aligned to was withdrawn, and the post-mortem is why ARKA no longer treats a regulation as demand.
1 January 2024
Evidence →None of our business case depends on any of these.
All patients, orders, and outcomes on this page are synthetic (ARKA-DEMO-001); no real patient data.
DEMO MODE
Demonstration only — not for clinical use.
Select a patient scenario to run through the utilization management workflow.
60 years old • Male
Primary Diagnosis
Lumbar Disc Herniation L4-L5
M51.16
37 years old • Female
Primary Diagnosis
Tension-type Headache
G44.209
68 years old • Male
Primary Diagnosis
Lung Nodule - Suspicious
R91.1