Administrative Agents

Automate core administrative tasks to reduce manual workload

Key Features

• Outreach Agent: Delivers member outreach across channels with personalized messaging.
• Conversational Agent: Ask any questions about your data population, risk, utilization etc.
• Appointment Agent: Manages scheduling, reminders, and rescheduling to reduce no-shows.
• Assignment Agent: Intelligently routes tasks based on team roles, capability and capacity.
• Consent Agent: Captures and tracks member consent across preferred channels.
• FWA Agent: Detects potential fraud, waste, and abuse via pattern analysis.
• Compliance Agent: Keeps you audit-ready by continuously monitoring compliance.

Impact: Plans running these agents have automated 95% of intake workflows, cut no-show rates 40%, and identified $1.2M in recoverable overpayments through continuous FWA surveillance.

Administrative Agents

Automate core administrative tasks to reduce manual workload

Key Features

• Outreach Agent: Delivers member outreach across channels with personalized messaging.
• Conversational Agent: Ask any questions about your data population, risk, utilization etc.
• Appointment Agent: Manages scheduling, reminders, and rescheduling to reduce no-shows.
• Assignment Agent: Intelligently routes tasks based on team roles, capability and capacity.
• Consent Agent: Captures and tracks member consent across preferred channels.
• FWA Agent: Detects potential fraud, waste, and abuse via pattern analysis.
• Compliance Agent: Keeps you audit-ready by continuously monitoring compliance.

Impact: Plans running these agents have automated 95% of intake workflows, cut no-show rates 40%, and identified $1.2M in recoverable overpayments through continuous FWA surveillance.

Appeals & Grievances Agents

Speed up resolution and improve member experience

Key Features

• Intake Agent: Captures and structures case details with guided workflows from multiple channels including AI OCR.
• A&G Clinical Evidence Agent: Summarized clinical data for medical necessity review while member data in focus.
• A&G Recommendation Agent: Provides recommendation to staff on case determination.

Impact: Average case turnaround reduced from 12 days to under 5.
100% of expedited appeals resolved within the 72-hour CMS mandate.
Member escalation rates dropped 45%.

Care Management Agents

Speed up resolution and improve member experience

Key Features

• Identification & Stratification Agent: Continuous ingestion of data for real time risk identification & stratification.
• Assessment Agent: Trigger various assessments and use Outreach agent to get them completed.
• Clinical Summary Agent: Get 360-degree view of Member or patient including executive summarization with SDoH.
• Personalized Care Plan Agent: Generate individualized care plans with detailed actions/interventions and goals defined.
• Task Completion Agent: Ensure completion of actions by member or patient or caregivers using Outreach agent and stay compliant and improve outcomes.
• Member engagement and Navigation Agent: Guide members to right care at right time.
• Care Coordination & Transitions Agent: Close loop across inpatient, ED and Post-acute. Use of RPM.

Impact: Care plan generation reduced from 45 minutes to under 8 minutes per member. HRA completion rates increased from 54% to 92%. Care manager caseloads expanded from 1:85 to 1:200+.

Claims Agents

Speed up resolution and improve member experience

Key Features

• Intake and Data normalization Agent: Intake claims through multiple channels including AI OCR and validates data.
• Coding and Edit validation Agent: Validates coding on claims, suggests corrections, cleans claim.
• Benefit & COB Agent: Validates benefits, deductibles, cost shares, max OOP and produces COB result object.
• Medical Necessity & PriorAuth review Agent: Generates medical necessity recommendation based on clinical guidelines.
• Pricing & Financial Adjudication Agent: Applies allowed amounts, modifiers, payment determination, generates 835 payloads and EOB. Creates Audit trails.

Impact: Manual claim reviews reduced 80%. First-pass denial rates down 35% through AI-powered coding validation. Adjudication cycle time reduced 60% with full audit trails.

Utilization Management Agents

Accelerate utilization reviews with AI‑powered support

Key Features

• a case intelligently.
• Validation Agent: Validates member, provider, benefits, any customer specific policies and calls the outreach agent.
• Clinical & Recommendation Agent: Gathers and summarizes relevant clinical data and provides recommendation. If approvals allowed, takes to closure and calls outreach agent.

Impact: Contract simulation reduced from weeks to hours. HEDIS/Stars measure gap closure improved 8-15 percentage points. Real-time visibility into risk-adjusted contract performance.