The Actava.ai Payer Operations Agent Library grew from 10 agents to 23.
The first 10 cover provider credentialing and payer enrollment, network adequacy, plan configuration, claims adjudication rules, member eligibility and onboarding, behavioral health prior authorization, continuous compliance monitoring, and value-based care performance. If you haven't browsed them, the library page has every one.
The 13 new agents take on the front line of two lines of business. Five work Medicare Advantage, from the first application to the final remittance. Eight work small group, from the census a broker sends to the renewal pricing that closes the year.
They also fit how payer operations really runs. A payer has thousands of distinct workflows, and vendors build for the few dozen with the biggest volumes. A welcome call, a participation re-test, and an accumulator date check all sit in the tail that stays manual. These agents work it.
That's 23 agents total. Each one runs on Actava.ai KORA, and the ones that touch a determination hand it to a person.
Here's what's new. Every agent name links to its page in the library.
Medicare Advantage enrollment and member services
Why it existsEvery Medicare Advantage enrollment and every member call answers to CMS. These three read the application, welcome the member, and answer the phone, all from sources a reviewer can audit.
Medicare Enrollment Desk
Reads one submitted MA-PD application and builds a single enrollment report. The report covers signature and Scope of Appointment, documents, BEQ eligibility, service area, election period, dual and LIS status, the CMS transaction and TRR outcome, fulfillment, and the notices due. It's read-only and writes nothing back. When no valid election period supports the enrollment date, the report says so, which puts the fix with an enrollment specialist at intake instead of in front of a CMS auditor.
Ask it to enroll a member without a valid election period and it declines to call that enrollment clean. The report flags the gap against the stated date so a specialist can resolve it or route it. Where dual or LIS status rests on thin source data, the report marks it unconfirmed and shows the basis next to the BEQ result.
View the Medicare Enrollment Desk in the library →
Member Service Desk (Voice)
Places the outbound welcome call to a new member. It verifies the member first, offers a menu of questions it can answer (benefits, PCP, cards, pharmacy), and answers each one from read-only tables. When a member raises a grievance or a coverage request, the agent captures it and routes it into the formal process with its timeline intact. The call ends with a spoken summary.
If a member complains mid-call, the agent acknowledges it, records it accurately, and routes it to the grievance process, because Medicare members hold grievance rights with timelines. Asked to change a PCP on the call, it explains how a change is made, logs the request, and leaves the change to the desk that owns it. The member gets a verified, on-record welcome and nothing drops.
View the Member Service Desk (Voice) in the library →
Member Service Desk (Incoming)
Answers the phone for members and providers. It identifies the caller, works from a 14-question menu, and answers from read-only tables and the Evidence of Coverage, so a copay quote comes from the member's own plan. When the source doesn't show a clear answer, it routes the question and skips the guess. Every call closes with a formatted contact record.
Providers get the same desk. The agent identifies a provider caller, applies the provider menu, shares what a provider is entitled to on that member, and notes on the contact record that it was a provider call. A confidently wrong benefit answer hurts more than a routed one, since members act on what the desk tells them.
View the Member Service Desk (Incoming) in the library →
Medicare Advantage authorization, claims, and payment
Why it existsAuthorization and payment are the two decisions regulators watch closest. These two keep a physician on every adverse call and apply member cost-share protections by rule.
Prior Authorization Desk
Reads one prior authorization request and writes a report that opens with a plain-language briefing for readers outside UM. Then comes the determination. It covers the decision clock from receipt, eligibility on the date of service, coverage criteria applied in NCD, LCD, then plan order, two-midnight level of care, network status, and notices to the provider, member, Claims Desk, and PCP. Gaps pend. Adverse determinations route to a physician reviewer.
Take a pacemaker request with thin clinicals. The agent reports exactly what's missing to meet criteria and pends the request for it. An adverse medical-necessity decision belongs to a physician, so the report routes there with the member's appeal rights. At each level it names the criterion met or unmet, such as NCD 20.8.3 for a pacemaker, which makes the basis auditable.
View the Prior Authorization Desk in the library →
Claim Review & Payment Desk
Adjudicates a member's inpatient facility, professional, and transitional care management claims against the prior authorization on file. It checks eligibility, matches the authorization, validates coding, prices against the contract, and applies sequestration, QMB cost-share protection, and Medicaid crossover. It closes with remittances and an EOB. The agent flags a claim that doesn't match its authorization and doesn't pay around it.
The law protects QMB members from Medicare cost-sharing, so the agent applies that protection, routes the protected share to Medicaid crossover where it applies, and shows the protected member responsibility on the EOB. Balance billing a QMB member is a specific compliance violation. Paying a claim that doesn't match its authorization starts overpayments and recoupments, so the report states where service, level of care, or dates diverge.
View the Claim Review & Payment Desk in the library →
Small group quoting, install, and enrollment
Why it existsA small group quote unwinds at install when the numbers rested on the wrong population. These two test participation at the quote and again against real elections.
Small Group Broker Quoting Desk
Takes one employer group from census to a producer-ready quote pack in a single run. It checks credentials, normalizes the census, determines group size, tests participation and contribution, pins the rate table, rates the census, and compares funding options. The pack carries a full audit trail. The producer releases the quote, and when a group fails participation the pack shows the shortfall and the change that would bring it in range.
Rate-table pinning sits on the audit trail. The effective date and the group's rating characteristics decide which table applies, and the agent records which one and why, so the quote can be reproduced and defended months later. If the effective date shifts, the pinned table shifts with it in plain view.
View the Small Group Broker Quoting Desk in the library →
Install & Enrollment Desk
Runs the six-step installation from released quote to issued cards and first invoice. It configures the install, opens the election window, re-tests participation against the elections that arrived, requests prior-coverage credits, issues documents and member cards, and sets the first billing expectation. A group that passed at quote can fail once real elections land, so cards wait until every gate clears.
Each step is a rule-based lookup or threshold test against stated criteria. The quote passed on the census, and install re-tests against who actually elected, since those are different populations. When the group no longer meets participation, the agent holds issuance on the failing gate and surfaces the shortfall for resolution.
View the Install & Enrollment Desk in the library →
Small group employer services and renewal
Why it existsAn employer who calls about one employee needs to know whether the change is allowed, when it takes effect, and what it does to the bill. These two answer all three, then price the next year.
Employer Service Desk
The desk an employer calls, run as a conversation. It answers the eligibility question in the employer's terms, records the change, and states the effect on next month's invoice in the same call. It detects qualifying events from the payroll feed, picks federal COBRA or state continuation, and issues the right material on time. It reissues cards and documents and reconciles the group bill line by line.
The agent reads the roster from the install report, so a change lands where the bill is computed, and it adds coverage from the date the qualifying event supports. If that date falls later than the one requested, it explains the difference to the employer on the call. For a departing employee it picks the continuation regime that applies to the group, because a late or wrong-regime notice is a compliance exposure.
View the Employer Service Desk in the library →
Renewal & Retention Desk
Reads each renewal group's year at T-120, covering utilization, size drift, waiver movement, participation, and any member case the Appeal Desk rolled up. At T-90 it breaks each rate change into age, area, trend, and benefit change, prices the renewal, and tests retention signals. At-risk groups release with an intervention attached and the rest release as standard. It never rates a group on its own claims, never names a member to an employer or broker, and never withholds a renewal.
Retention runs on honest rate explanations. The employer sees how much of the change came from age, area, trend, and benefit, which is the allowable explanation. At-risk groups get an intervention, and every group gets a renewal that arrives on time. Small group rules keep an individual's health out of the conversation, and this agent follows them.
View the Renewal & Retention Desk in the library →
Small group authorization, claims, and appeals
Why it existsFour desks, four questions, one claim. Each desk reads the answer before it and stays inside its own.
Prior Authorization Intake Desk
The first desk a submission reaches. It registers the request and stamps the receipt date that every downstream clock runs from. It decides whether prior authorization is required at all, applies the three-element test for whether a claim exists, sets urgency, inventories the attachments, and routes to clinical review. It holds no medical policy, so it never reviews, qualifies, or denies.
Intake sets clinical review up to move fast. A correct receipt date, a clean required-or-not decision, established urgency, and a full inventory of attachments arrive together. Urgency comes from what the submission states, and an ambiguous submission gets marked ambiguous. An approval from a desk with no medical policy would have nothing behind it, so approval stays with clinical review.
View the Prior Authorization Intake Desk in the library →
Claim Review Desk
Answers one question about one claim, which is whether the bill is correct. It reads the eligibility result without re-deciding coverage, confirms the billed lines sum to the claim total, and tests every line against every billing rule. The report lists the rules that passed alongside the one that failed. It removes the lines the rules remove and states the allowed amount.
Showing the passes makes the one failure legible and the review defensible. The failed rule and the resulting allowed amount sit at the top, with the cleared rules beneath for the audit trail. If the eligibility result itself looks wrong, the agent flags it and leaves coverage alone, so two desks never reach two answers on the same claim.
View the Claim Review Desk in the library →
Payment Desk
Answers who pays what. It takes the allowed amount from claim review, confirms the deductible is met, applies the copay first and coinsurance to the remaining balance, and reconciles plan share and member share back to the allowed amount before it publishes the split. Cost-share runs off allowed, never billed.
Order matters. Copay comes first, then coinsurance on what remains, because reversing them changes the member's share. Using the billed amount would charge the member for a difference the contract already wrote off. When the split doesn't tie back to the allowed amount, the agent treats it as a sign that something upstream is off and flags it.
View the Payment Desk in the library →
Appeal Desk
Answers whether the member is being asked for too much. It states the member's ground in her own terms before testing it, then checks that the accumulator is dated on or before the date of service before using a figure from it. It works out how much out-of-pocket maximum was still payable that day, caps the member's share there, and moves the excess to the plan. Where the member is right, it says upheld before it shows the arithmetic.
Date-checking the accumulator matters. A total pulled today would apply spending that happened after the service to a day it hadn't happened yet, and that changes the member's answer. If the agent can't confirm the accumulator predates the service, it says so. An appeal stays on the member's share, and a bill error goes back to claim review.
View the Appeal Desk in the library →
Why every desk owns one decision
Follow a small group claim through the last four agents. Intake stamps the receipt date and routes. Claim Review decides whether the bill is correct and stops at the allowed amount. The Payment Desk splits that amount between plan and member. The Appeal Desk tests whether the member's share ran too high, and the Renewal Desk reads what the Appeal Desk rolled up when it prices the next year.
Each desk reads the result of the one before it and leaves it settled. Claim Review takes eligibility as given. Payment takes the allowed amount as given. Two desks never reach two answers on the same claim.
We built it this way on purpose. On Ļ-BENCH, frontier models fail 72% of complex U.S. healthcare workflows, and fewer than 8% of agents stay successful when a task repeats. Our bet is that a narrow job with a clear input and a clear stop gives an agent better odds than a broad one.
The Medicare Advantage agents apply the same discipline to regulation. The Prior Authorization Desk pends on gaps and sends adverse determinations to a physician. The Claim Review & Payment Desk applies QMB protection by rule. The Member Service Desk (Voice) puts a grievance on the record with its timeline intact.
Every agent builds and runs on Actava.ai KORA, with HIPAA controls and an audit log on every action. Actava.ai Compliance governs them from one place, and CURA, our healthcare model, can run in your own cloud.
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Open any of the 23 agents and name the workflow your team still runs by hand. We'll show you the first agent working against it.
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