Use Case 1
New Plan Build to Go-Live
Trigger: Plan documents received for upcoming effective date
1.Ingest SPD/SBC/benefits grid; extract BH parameters per plan × network tier
2.Translate parameters into CAPS rules expanded to specific service codes
3.Configure BH carve-out routing to vendor (Magellan, Optum BH, Carelon) with EDI loops
4.Run MHPAEA parity check across six classifications with state law overlays
5.Load fee schedules with modifier and POS pricing, including telehealth parity
6.Generate plain-language benefits summary for analyst review (HITL)
7.Run 15+ adjudication regression scenarios per plan
8.Route go-live briefing for benefits manager approval (HITL with financial accountability attestation)
9.Generate member-facing benefits guides and provider directory after approval
✓
Plans go live with parity verified, regression tests green, and a documented sign-off chain from analyst through manager.
Use Case 2
Mid-Year Plan Amendment
Trigger: Regulatory change, employer-requested change, or compliance remediation
1.Classify trigger type and identify impacted plans and configs
2.Run impact assessment (parity re-check needed? rate changes needed?)
3.Route to regulatory reviewer for change scope approval (HITL #1)
4.Re-run impacted phases—config, parity, rates, regression—never skipping parity
5.Route to benefits manager for amendment go-live approval (HITL #2, separate person)
6.Generate member notification per ERISA 60-day rule or regulatory timeline
7.Trigger member materials regeneration
✓
Amendments process with two-person regulatory and benefits-manager attestation, full re-test, and no parity surprises.
Integrations
CAPS Platforms (Facets, QNXT, HealthRules)
BH Carve-Out Vendors (Magellan, Optum BH, Carelon, Beacon)
Plan Document Repository (SPD, SBC)
Fee Schedule Source (Medicare PFS, Contracted)
MHPAEA Comparative Analysis Library
Member Materials Generation
Industries
healthcare
See It In Action
A sample conversation with this agent
Configure the new MetroHealth EPO Silver plan for April 1 go-live.
Phase 1: parsing SPD, SBC, and benefits grid into structured BH parameters—one row per plan × network tier. Phase 2: expanding benefit categories into CPT/HCPCS/REV codes for HealthRules (BH-OUTPT-IND-PSYCH → 90832, 90834, 90837; IOP → REV 0905; PHP → REV 0912/0913). Phase 3: Magellan carve-out routing rules with the 2010BB EDI loop and vendor payer ID. Phase 4 parity check is the gate I'm watching most closely—I'll run substantially-all and predominant tests across all six MHPAEA classifications before I touch regression.
Why is the parity check flagging the 20-visit outpatient BH cap as critical?
Three reasons converging. One, medical/surgical outpatient is unlimited in the same classification, so the BH limit fails substantially-all and predominant. Two, the 2024 MHPAEA Final Rule comparative analysis treats this as an NQTL-disparate-application issue, not just a QTL. Three, the plan covers Illinois which adds HB-2595 SUD parity overlay. Severity is critical because remediation requires removing the cap, not adjusting it. I'm setting ready_for_go_live=N and writing a remediation plan with CFR and state law citations. Phase 8 cannot approve this plan without explicit operator override.
TechFlow wants a mid-year amendment to add G0560 collaborative care.
Treating this as Phase 10. Trigger type regulatory (CMS PFS 2026 Q2 expansion), impacted plan PLN-2026-2891, impacted configs CFG-00013 family. Re-running Phase 5 to add the rate row and Phase 4 parity check—it's additive coverage so parity risk is low, but I never skip the re-check. Two HITL gates needed: regulatory reviewer for change scope, then benefits manager for go-live re-approval. Same person can't hold both roles. ERISA requires 60-day member notice if member cost-share changes; this one doesn't, so notice timeline is regulatory-driven.