Use Case 1
Multi-Payer Enrollment Pipeline
Trigger: Newly credentialed provider requires enrollment with target payers
1.Verify provider cleared credentialing and recredentialing not due soon
2.Map payer requirement by payer × provider type × state
3.Pre-fill application from full provider profile with NPPES cross-check
4.Run QA checks (document expirations, malpractice minimums, work history gaps)
5.Route to credentialing specialist for QA approval gate
6.Submit via the channel specified by payer (portal, EDI, fax, PECOS)
7.Track status with daily portal polling and 30/60/90-day follow-ups
8.Handle deficiencies by matching existing documents and routing draft response for approval
✓
Provider reaches active in-network status in roughly half the typical industry cycle, with full audit trail.
Use Case 2
Contract & Rate Negotiation Support
Trigger: Payer returns approved application with contract attached
1.Parse contract clauses into structured review record (termination, reimbursement, audit, timely filing, BH carve-outs)
2.Score risk per clause and route to legal for mandatory human gate
3.Compare proposed rates to Medicare benchmarks and existing contract book
4.Generate ACCEPT or NEGOTIATE recommendation with revenue impact projection
5.Route to leadership for negotiation decision (mandatory human gate)
6.Log every negotiation round with counterparty and our response
7.Record contract execution with DocuSign envelope ID and effective date
✓
Leadership negotiates with full benchmarking data; legal sees risky clauses surfaced; nothing executes autonomously.
Use Case 3
Roster Submission & Directory Verification
Trigger: Contract executed with effective date within 30 days
1.Generate roster file with NPI, location, taxonomy, panel status
2.Submit roster to payer via contract-specified channel
3.Poll payer provider directory for listing presence and accuracy
4.Flag discrepancies and submit corrective actions (No Surprises Act compliance)
5.Activate network participation record on confirmation
✓
Provider listed accurately in payer directory by effective date with NSA compliance documented.
Integrations
CAQH ProView
PECOS / Medicare Enrollment
Payer Provider Portals (Availity, NaviNet, Aetna, Cigna, UHC)
EDI 837P Submission
Contract Repository & DocuSign
Rate Benchmarking (Medicare PFS, Market Comparables)
Approval Workflow (RequestApproval)
Industries
healthcare
See It In Action
A sample conversation with this agent
Start enrollment for Dr. Reyes with Aetna in California—she just cleared credentialing.
Eligibility gate first: credentialing_cleared TRUE, recredentialing not due within 90 days. Loading payer requirement for Aetna × Behavioral Health × CA: portal submission, 45-day typical turnaround, 11 required documents. Pre-filling the application from her full profile with NPPES cross-check—name, specialty, and primary location all match. All 11 documents current and within expiration. QA checks pass. Routing to credentialing specialist for human gate review before I submit.
The contract for Dr. Patel with Cigna came back with a clause flagged HIGH risk—what happened?
Cigna's draft contains a unilateral termination-without-cause clause with a 60-day notice, which is shorter than the 180-day floor in our existing contract book. I've parsed all clauses into the review record and tagged the termination clause HIGH. Also flagged: their timely-filing window is 90 days vs. our standard 180. Both go to legal as escalation notes. I'm not authorized to negotiate—holding the contract in UNDER_REVIEW until legal returns APPROVED, APPROVED_WITH_CHANGES, or REJECTED.
Run rate analysis on the Magellan contract.
Comparing 47 BH CPT codes against three benchmarks. Average percent of Medicare: 94% (proposed) vs. our book median 108%. vs. market median: -11%. Versus our existing executed contracts in CA: -$8.40 per psychotherapy 90834 visit, projecting roughly $340K annual revenue gap at expected volume. Recommendation: NEGOTIATE. Five highest-impact codes to push on: 90837, 90834, 90791, H0015, 90847. I'll route the analysis package to leadership but I won't accept or counter rates on my own.