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The Care Intelligence Platform

A review-ready case, and an accountable path after approval.

Keep the available requirement source, missing evidence, reviewer decision, execution rail, and external status connected from preparation through reconciliation.

Start with AssistSee a sample PA case

What is the Upstream platform?

Upstream gives procedural specialty teams one place to review what a prior authorization requires, what the case is missing, what action is proposed, and what still needs follow-up. Connected rails remain capability-gated, and payer-facing work begins only after approval.

The five capabilities

Prior authorization

Prepare the request the way the payer will actually review it.

Prior authorization leads because it is where fragmented evidence becomes avoidable rework. Upstream reads the available governing policy, builds the requirement checklist, and keeps unsupported or missing facts visible before a reviewer approves the next step.

  • Requirement checks show their source and effective date when available.
  • Unknown policy and missing evidence remain explicit case states.
  • The proposed payload and destination stay held for reviewer approval.

Payer requirements

Sample data
  • Clinical criteriaMet
  • ICD-10 and CPT alignmentVerified
  • Functional baselinesConfirmed
  • Step-therapy history, 6 monthsNeeds evidence
Readiness: Needs evidence. One item open before submit.
Payer-policy monitoring

See the policy move while there is still time to act.

Published coverage policies change over time. Upstream versions the sources it ingests and can surface relevant changes without converting a missing source into a confident answer.

  • Published policy identifiers and effective dates remain attached.
  • Relevant changes can be reviewed by payer and procedure.
  • Missing or stale source coverage remains visible to the operator.

Care signal

Sample data

Aetna tightened step-therapy for infusion biologics.

High
Root causePolicy Drift
ProcedureJ3490 infusion biologic
At risk12 open requests
Benefits and eligibility

Verify coverage before the rest of the work stacks up.

For practices with an approved Stedi configuration, eligibility can add current coverage and benefit context before a payer-facing action is prepared.

  • Eligibility uses the configured 270/271 rail, not the prior-auth submit path.
  • The payer context follows the case into prior authorization and denial management.
  • Unavailable or unknown responses remain visible instead of becoming synthetic coverage.

Coverage verification

Sample data

UnitedHealthcare, infusion visit

Coverage active
Prior authorizationRequired
Deductible remaining$180.00
Estimated out of pocket$42.00 per visit
Verified before the visit, not after the write-off.
Denial management

Run the appeal and follow-up work with the payer context intact.

A denial should not detach the response from the original case. Upstream can carry the requirement, supporting rationale, approved action, and confirmed disposition into the next review.

  • Appeal and follow-up work starts from the payer signal, not from scratch.
  • Prepared denial-management work stays approval-gated and fully auditable.
  • Only confirmed outcomes enter the outcome ledger.

Denial cluster

Sample data

Cigna, CO-197 on chemo administration 96413

9 denials
Root causeDenial Pattern
Appealable9 of 9
Prepared actionSubmit Appeal
Revenue intelligence

See what is slipping before it shows up in the numbers.

Confirmed approvals, denials, recoveries, and timing can be reviewed by payer and procedure without mixing detected risk with recognized financial outcomes.

  • Confirmed dispositions separated from predictions and estimates.
  • Payer and procedure views grounded in recorded outcomes.
  • Outcome evidence retained with the action that produced it.

Revenue risk

Sample data

Humana paying 96365 below contract since March

Watching
Variance18% under contract
Affected41 paid claims
Exposure$12,300
Rate variance stays under watch after recovery.
Why teams pick Upstream

Prior authorization is the front door. The whole case is the difference.

Plenty of tools touch prior auth. Fewer carry the entire case, in the specialties where payer friction hits hardest, while there is still time to act.

The next action stays clear

Requirements, missing evidence, the approved packet, and follow-up stay connected instead of splitting across portals and spreadsheets.

The source stays attached

When a governing policy is available, Upstream shows the source and effective date. When it is not, the case stays explicitly unknown.

The decision stays with your team

A reviewer sees the proposed action, destination, evidence posture, and unresolved gaps before approving a payer-facing step.

The attempt stays accountable

Approved work is tied to its payload, rail, owner, attempt state, and reconciliation evidence instead of disappearing into an untracked send.

The Upstream Data network

A separate non-PHI surface with explicit provenance.

Upstream Data exposes policy requirements, privacy-thresholded benchmarks, and a truth-labeled risk response for builders. Sandbox responses are synthetic. Live benchmarks are computed from contributing claim records and withheld below the privacy threshold.

  • Benchmarks by payer and procedure only when enough practices contribute.
  • Four API contracts with a synthetic sandbox and scoped live keys.
  • Model status returned with every denial-risk response.

Standard payer APIs are expanding. Capability still has to be verified tenant by tenant.

Upstream is designed to consume standards-based payer information as endpoints become available. A live FHIR PAS rail is enabled only after its endpoint, BAA posture, payer enrollment, and recent capability verification are confirmed for the tenant.

Verified
Live electronic PA requires a tenant-ready endpoint and payer enrollment.
Assigned
Without a verified electronic rail, approved packets move to an auditable human path.
Waiting
Submission is not treated as a payer outcome.
Reconciled
Terminal status requires structured external evidence.

Approval starts an accountable attempt, not a promised outcome.

Upstream records the reviewed payload, selected rail, owner, and attempt state. Waiting, blocked, failed, and unknown outcomes remain work to resolve, not quiet successes.

Start with a clearer next action.

Open a workspace on the free Assist plan, or walk through a synthetic prior authorization case before you decide.

Start with AssistSee a sample PA case