Use Case 1
New Patient Eligibility & Cost Estimate
Trigger: Patient scheduled or arriving for visit
1.Capture insurance card via image upload or OCR
2.Resolve payer ID against directory; flag unmappable plans
3.Run 270 eligibility request and parse 271 response
4.Cascade through BH carve-outs (Magellan, Optum BH, Carelon) when present
5.Extract plan-specific benefits: copay, deductible, coinsurance, visit limits, PA requirements
6.Calculate patient out-of-pocket estimate at contracted rate
7.Draft patient-facing communication in preferred language
8.Route communication for front-desk review before send (HITL gate)
✓
Patient knows what they'll owe before the visit; staff handles only exceptions, not every check.
Use Case 2
Daily Panel Pre-Verification
Trigger: Next-day appointment list assembled
1.Pull all scheduled patients for next business day
2.Re-verify eligibility for each (catch coverage changes since last visit)
3.Flag deductible resets, plan changes, terminated coverage
4.Update EHR with current eligibility and cost-share
5.Route exceptions for front-desk attention
✓
Front desk arrives with a verified panel and a short exception list, not 30 manual lookups.
Integrations
270/271 Eligibility (X12 / FHIR R4)
BH Carve-Out Vendors (Magellan, Optum BH, Carelon)
EHR / Practice Management (Epic, athenahealth, NextGen)
OCR / Insurance Card Capture
Patient Messaging (multilingual)
NPPES NPI Registry
Industries
healthcare
See It In Action
A sample conversation with this agent
New patient checking in—Maria Santos, here for her first BH intake.
Capturing her insurance card image. OCR extracted: Aetna, member ID 123456789, plan code BH-OPEN-CHOICE-PPO, group 478392. Resolving to payer ID 60054 in our directory. Running 270 eligibility request. 271 came back: active coverage as of January 1, in-network for her PCP, $30 BH copay in-network, $500 deductible (47% met), no PA required for outpatient psychotherapy. Carve-out cascade: this plan is administered in-house, no vendor handoff. Building her cost estimate now.
Why are you saying we need to call Optum BH for James Patel's visit?
His Aetna plan ID resolved cleanly, but the 271 response shows BH-CARVE-OUT to Optum (vendor payer ID 87726) for outpatient behavioral health. That means Aetna's medical eligibility doesn't tell us his actual BH benefit—we need a separate eligibility check against Optum to get his BH copay, visit limits, and PA requirements. I've drafted the Optum 270, but I won't transmit it without front-desk approval since it's a second payer interaction. Once approved, I'll run it and finish his estimate.
Generate the cost estimate for tomorrow's intake panel.
8 patients on Dr. Chen's tomorrow panel. Estimates ready: 5 in-network with simple plans (estimates from $30 to $75 per visit), 2 with BH carve-outs requiring vendor eligibility (running tonight), 1 with a deductible reset issue—patient hit the new plan year and likely owes the full $185 contracted rate until $500 deductible is met. I've drafted patient-facing estimates in Spanish and English per preferred language. Holding all communications for front-desk review before they go out tomorrow morning.