AI denial risk is now a number the board risk committee asks for.
Tokto gives the health plan's risk and compliance officer one record that ties every AI denial, every clinical review, and every PHI flow to a member, a plan, and an authorization, ready for CMS, OCR, the state DOI, the audit committee, and the board risk committee.
A federal court orders disclosure of the AI tool behind post-acute denials. CMS asks about the program-audit posture. The board risk committee asks the CRO for the AI denial reversal rate and the control that requires clinical review. The risk function has a model inventory and a RAG status, but no per-member record of whether a human ever reviewed a denial.
- Every AI denial scored and recorded against a member, a plan, a clinician, an authorization, and a denial code.
- A single evidence layer that CMS, OCR, the state DOI, the HIPAA auditor, and the board risk committee read against the same record.
- Policy enforced at the prompt: no AI denial without clinical review, no PHI to a vendor without a contract.
- AI risk that is measured by reversal rate, controlled at the prompt, and attestable to the board.
- AI denial risk is never quantified. The first number is a 90 percent reversal rate in a class certification.
- An ambient scribe records patients without consent. The control gap opens CIPA exposure.
- A vendor with PHI access has no current BAA. The risk register never flagged the lapse.
- The board risk committee asks if AI denials are within appetite. The CRO has a heat map, not a record.
Tokto turns AI utilization management into a measured, controlled risk. Every UM co-pilot, every ambient scribe, every prior-auth triage model becomes a scored record at the moment of output, tied to the member, the plan, the clinician, and the review that did or did not happen. The risk function can finally put a number on AI denial exposure.
When a court orders algorithmic disclosure, when CMS runs a program audit, when the board risk committee asks whether AI denials are within appetite, the answer is one query against the system of record. The CRO reports AI denial risk the way every other reserve-driving risk is reported.