InsuranceTimely determinations, accurate payments, every decision defensible.
ACTAVA puts agents to work across health plan and insurance operations, from prior authorization and claims to appeals, enrollment and renewals, while a credentialed person holds every determination.
Agents Prior Authorization Desk Outpatient physical therapy, 12 visits
Requests
- Outpatient physical therapyRoutine · received todayPended
- MRI, lumbar spineRoutine · received yesterdayReady for review
- Home oxygen equipmentExpedited · 72 hour clockIn progress
Request
- Member
- Rosa Delgado
- Plan
- Lakeview Medicare Advantage
- Requested by
- Harbor Street Rehab
Run
- Receipt stamped, decision clock running
- Eligible on the date of service
- Criteria applied in order: NCD, LCD, plan policy
- In network
- One criterion needs recordsPended, not denied
Sent to the provider's office
Human Approval
Physician reviewerHolds the determination
issue_determination Reviewer onlyAn agent for every desk in the plan.Start where your team still works by hand.
Prior authorization worked to the criteria, with a physician on every adverse decision.
- Compliance checksPrior Authorization DeskChecks the decision clock, eligibility, coverage criteria in NCD, LCD then plan order, and network status. Pends on gaps instead of denying, and routes adverse determinations to a physician reviewer.Open the agent
- Compliance checksPrior Authorization Intake DeskRegisters each submission, stamps the receipt date every clock runs from, decides whether authorization is required, sets urgency and routes. It holds no medical policy, so it never denies.Open the agent
- Compliance checksBehavioral Health Prior Authorization AgentRuns the behavioral health authorization lifecycle from requirement check and clinical packet through concurrent review and denial review with peer-to-peer coordination.Open the agent
Each claim checked against the authorization, the billing rules and the plan's cost share.
- Compliance checksClaim Review & Payment DeskAdjudicates facility and professional claims against the authorization on file: eligibility, coding, contract pricing and cost-share protection, closing with remittances and an EOB.Open the agent
- AI-assistedClaim Review DeskAnswers one question about one claim, whether the bill is correct, and reports the rules that passed as well as the one that failed before stating the allowed amount.Open the agent
- AI-assistedPayment DeskWorks out who pays what from the allowed amount: deductible, copay, then coinsurance, reconciled back to the allowed amount before the split is published.Open the agent
- Human approvalClaims Adjudication Rules AgentConfigures claims edit rules and code mappings, runs test claim batches, and puts every rule change through approval before it reaches production.Open the agent
The member's case stated in their own terms, tested, and recorded with its rights intact.
- Compliance checksAppeal DeskTests whether a member is being asked for too much: states their ground first, checks the accumulator against the date of service, and caps the member's share at what was still payable.Open the agent
- Human approvalMember Service Desk (Voice)A welcome call for new Medicare Advantage members that recognizes a grievance or coverage request when it comes up, captures it and routes it into the formal process.Open the agent
Enrollment checked before it goes in, and member questions answered from the plan's own documents.
- Compliance checksMedicare Enrollment DeskReads one submitted application and reports signature, documents, eligibility, service area and election period, flagging any gap instead of assuming the enrollment is clean.Open the agent
- AI-assistedMember Service Desk (Incoming)Identifies the caller, answers from read-only tables and the Evidence of Coverage, and closes every contact with a formatted record.Open the agent
- Human approvalMember Onboarding AgentMoves new enrollments through health risk assessment scoring and primary care assignment, with clinician review and crisis outreach as human gates.Open the agent
- Human approvalMember Eligibility Verification AgentResolves the payer, runs the eligibility check, extracts plan-specific benefits and produces a cost estimate before the visit.Open the agent
Quote, install, service and renew small group business, with people releasing every quote.
- AI-assistedSmall Group Broker Quoting DeskTakes an employer census to a decision-ready quote pack: size, participation and contribution tests, rating and funding comparison. It prepares the pack; a producer releases it.Open the agent
- Compliance checksInstall & Enrollment DeskCarries a released quote through install configuration, the election window, a participation re-test, card issuance and the first invoice.Open the agent
- Human approvalEmployer Service DeskAnswers the employer's eligibility question, records the change and states its effect on next month's invoice in the same call.Open the agent
- AI-assistedRenewal & Retention DeskReads a renewal cohort's year early, breaks each rate change into age, area, trend and benefit change, and routes at-risk groups with an intervention.Open the agent
Credentialing, plan setup and regulatory change kept current, with the evidence assembled.
- Compliance checksProvider Credentialing AgentRuns the NCQA credentialing workflow from NPI validation through primary source verification and exclusion screening to a committee-ready packet.Open the agent
- Compliance checksNetwork Adequacy & Optimization AgentValidates provider directories and runs CMS Medicare Advantage network adequacy calculations, targeting recruitment to the gaps.Open the agent
- Compliance checksPlan Configuration AgentTurns benefit documents into system-ready rules, validates parity, and runs regression tests before go-live through human gates.Open the agent
- Compliance checksContinuous Compliance Monitoring AgentWatches regulatory updates continuously and produces remediation packages ready for legal review.Open the agent
“As we take on more clients and business complexity, there won’t be a matching cost curve in finance. Cash applies on the day it deposits now, and my team scales with the book rather than behind it. ACTAVA has changed that equation for us with their agentic solutions.”
Bryan PerlerChief Financial Officer, Vālenz HealthFull story Built for regulated decisions
Agents prepare the work and show their reasoning. People decide, and the record shows who decided what.
- A person holds every determinationA credentialed reviewer makes each determination, favorable or adverse. Overriding the agent takes a documented rationale.
- Pend on a gap, never guessWhen the record is thin, the agent asks for what is missing instead of denying, and the clock it runs on is visible.
- Evidence travels with the workThe policy version, the criteria applied and the source documents sit beside each recommendation, and every action lands in the audit log.
- Your model, in your cloudRun CURA, frontier models or both inside your environment. Your data never trains CURA.
Approvals Outpatient physical therapyWaiting for you
Agent recommendationPend for records
Evidence attached
- Request and attachments, as received
- Criterion 3: progress notes missing
- Plan policy, section and version used
- Clock: 9 days left of 14
Approve pendOverride, with rationale
Audit log
- 9:14Agent pended the request for records
- 9:15Request for therapy notes sent to the provider
- 9:15Assigned to a physician reviewer
Payer work is hard.We measured how hard.
χ-Bench, our open benchmark, runs agents through realistic utilization management and prior authorization cases inside simulated payer and provider systems. Even the best of them fall short, which is why every ACTAVA agent is tested on your own cases before it goes live.
Read the χ-Bench study- Best pass@1 on χ-Bench's 25 utilization management tasks
- 41.3%
- Reliability: no agent passes the same task three runs in a row more than a fifth of the time
- <20%
- Prior authorization pass rate in χ-Bench's end-to-end arena, once a provider agent and a payer agent (both Codex + GPT-5.5) work the case together
- 0%
- Policy documents in the managed-care handbook the tasks are graded against
- 1,279
Plans, and the firms that serve them.Already at work with ACTAVA.
Our customers- Same dayCash application, on the day of depositVālenz Health applies cash on the day it deposits, with people in control of every posting. Read the Vālenz Health story.
30 daysFrom first agent build to productionMomentum Actuarial scaled clinical vendor evaluation 100x without adding analysts or compromising depth. Read the Momentum Actuarial story.
Name the desk your team still runs by hand.
We'll show you the first agent working against it, on your cases, with your reviewers in control.