Use Case 1
Quarterly Directory Accuracy Sweep
Trigger: 90-day No Surprises Act verification window
1.Pull all in-network providers from current directory
2.Verify phone, address, panel status, accepting-new-patients via outbound check
3.Cross-reference current credentialing roster
4.Flag discrepancies by category and severity
5.Draft corrective action items per provider
6.Route to network operations for HITL approval before publishing
7.Update directory and log verification with source and timestamp
✓
Directory stays NSA-compliant with documented verification cycles, not annual cleanups.
Use Case 2
Network Adequacy Filing Prep
Trigger: CMS Medicare Advantage filing window or state DOI submission
1.Run adequacy calculation by specialty × county against CMS thresholds
2.Identify gaps and prioritize by member impact
3.Generate recruitment targets ranked by gap closure value
4.Stress-test against likely contract terminations and provider attrition
5.Assemble adequacy filing package with documentation
6.Route to leadership for strategic decisions
✓
Filings submitted on time with adequacy demonstrated; gaps surfaced months before they become regulatory issues.
Use Case 3
Targeted Provider Recruitment
Trigger: Adequacy gap identified or strategic network expansion
1.Identify specialty × geography targets from gap analysis
2.Source candidate providers from external directories and referrals
3.Draft outreach communications per target
4.Route outreach for HITL approval before send
5.Track engagement and route interested candidates to credentialing pipeline
✓
Recruitment targets the specific gaps that actually move adequacy, not generic provider lists.
Integrations
Provider Directory Platform
CMS MA Adequacy Standards Database
State DOI Network Adequacy APIs
NPPES NPI Registry
Outbound Verification (phone, mail)
Approval Workflow (RequestApproval)
Industries
healthcare
See It In Action
A sample conversation with this agent
Run network adequacy on our MA contract for Texas.
Pulling current network for the TX MA service area. CMS adequacy by specialty: Primary care meets county-level access in 47 of 50 counties. Cardiology fails in 8 rural counties—time/distance threshold breached. Behavioral health fails in 14 counties (most common gap nationwide). Cross-referencing pbo6no_list_adequacy_calculations confirms the failures aren't just our model. Recruitment targets generated: 28 PCPs, 14 cardiologists, 31 BH providers prioritized by county impact. I won't initiate outreach until ops confirms the recruitment plan—that's a HITL gate.
Why are 312 of our directory entries flagged?
Quarterly directory accuracy audit ran overnight. Failures by category: 184 phone numbers verified disconnected or wrong-number, 67 'accepting new patients' fields stale (provider responded NO when verified), 43 specialty mismatches between roster and current credentials, 18 location addresses outdated. Under No Surprises Act, directory data must be verified every 90 days. I've drafted corrective action items per provider; they go to network operations for confirmation before I publish updates. Anything I publish gets logged with verification source and timestamp.
Project our adequacy if we lose our top 3 BH groups in California.
Stress test running. Removing the three groups (combined 47 BH providers across 9 counties) drops CA BH adequacy from 89% to 61% county coverage. Three counties go from adequate to non-adequate immediately. Two more sit within 5 percentage points of failure. Medicare Advantage filing risk: HIGH—network would not pass CMS adequacy at next filing window. Recruitment urgency: critical. Estimated outreach to backfill: 60 BH providers minimum, 90-day timeline. Routing this to leadership as a strategic decision, not an operational one.