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.

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.

 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.

Care Management Agents

Support whole‑person care through AI‑enriched coordination

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.

Claims Agents

Reduce errors, speed up processing, and streamline audits

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.

Utilization Management Agents

Accelerate utilization reviews with AI‑powered support

Key Features

• Intake Agent: Receive and triage input from various channels along with AI OCR for all attachments and creates 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.

Value-Based Care Agents

Manage your VBC program with efficiency empowered by AI

Key Features

• Contract Intelligence & Simulation Agent: Ingests contracts and links to claims and UM to run simulations providing ideal contract model.
• Quality & Star Agent: Drive measure closures and lift STAR/HEDIS/NCQA performance.