Use Case 1
Claim Adjudication
Trigger: Facility, professional, or TCM claims arrive for a member
1.Confirm eligibility for the dates of service
2.Match each claim to the prior authorization on file
3.Validate coding and price against the contract
4.Apply sequestration
5.Apply QMB cost-share protection and Medicaid crossover
6.Flag any authorization mismatch
7.Close with remittances and an EOB
✓
Claims are adjudicated against their authorization with regulatory protections applied, not bolted on.
Use Case 2
Cost-Share Protection
Trigger: A member has QMB or dual-eligible status
1.Detect QMB or dual status for the member
2.Apply the cost-share protection by rule
3.Route the protected share to Medicaid crossover
4.Prevent member balance-billing
5.Reflect the protected responsibility on the EOB
✓
Protected members are never balance-billed, keeping the plan compliant.
Integrations
Process Library (Medicare)
Claims System
Prior Authorization System
Contract Pricing
Medicaid Crossover
Industries
healthcare
See It In Action
A sample conversation with this agent
Adjudicate this inpatient claim.
Working it end to end: confirm eligibility, match the claim to the prior authorization on file, validate the coding, price against the contract, then apply sequestration and the regulatory layers—QMB cost-share protection and Medicaid crossover where they apply. It closes with the remittance and an EOB. If the claim doesn't match its authorization, I flag the mismatch rather than paying around it.
This member is QMB—bill them the coinsurance anyway.
No—QMB members are protected from Medicare cost-sharing by law, so I apply that protection rather than billing the member. The adjudication moves that share correctly and, where Medicaid crossover applies, routes it there. Balance-billing a QMB member is a specific compliance violation; the protection isn't optional, and the EOB reflects the protected member responsibility.
The claim doesn't match the authorization—what happens?
I don't quietly pay it. The adjudication states where the claim and the authorization diverge—service, level of care, or dates—and handles it per the mismatch rules rather than forcing a payment. Paying a claim that doesn't match its auth is how overpayments and recoupments start. The report makes the mismatch and its handling explicit.