Agents that learn your intake team.
Every request has to reach the right member, plan, and benefit before anyone can review it. The agent learns the checks your intake team actually runs.
Where the time goes
Requests arrive by fax, portal, and EDI, and get keyed into the case system by hand. Member matching fails on name, date-of-birth, and ID discrepancies, one case at a time. Misrouted cases and wrong benefit assignments surface later as rework and missed turnaround.
What the agent takes on.
Learns which discrepancies your intake team resolves themselves and which ones they escalate Reads the incoming request and opens the case in your system Matches the member, plan, and benefit, and confirms eligibility on the date of service Determines the review type and routes the case to the right queue Resolves the discrepancies it has judgment for, and flags the rest
Where your staff set the guardrails
The agent resolves member, plan, and benefit discrepancies on its own judgment, and routes only what it cannot You set which discrepancy types a person must confirm before a case moves Every match, eligibility check, and routing decision is recorded in the audit trail