Use Case 1
834 Enrollment Processing
Trigger: 834 batch received from exchange or employer feed
1.Validate transaction completeness and field-level integrity
2.Build member records with dependent linkages
3.Run plan eligibility and effective-date checks
4.Assign preliminary PCP based on geography and relationships
5.Generate welcome packet and HRA invitation
6.Route SEP, COBRA, and court-ordered exceptions for human review
7.Activate member in operational systems
✓
Standard enrollments process automatically; exceptions land on the right human worklist with full context.
Use Case 2
HRA Workflow with Crisis Gate
Trigger: Member completes Health Risk Assessment
1.Score HRA across physical, behavioral, and social domains
2.Flag crisis indicators (active SI, severe depression, acute SUD)
3.For non-crisis: route to risk tier and trigger appropriate engagement track
4.For crisis: lock automated outreach, page on-call BH clinician, alert care manager
5.Track clinician response time against 48-hour SLA
6.Document outreach outcome and next steps
✓
Crisis cases reach a human clinician fast; routine HRAs trigger the right care track without manual triage.
Use Case 3
First-90-Day Engagement Cadence
Trigger: Member activated in plan
1.Welcome touch within 7 days (preferred channel)
2.HRA invitation at day 14 with reminders
3.PCP confirmation outreach at day 30
4.First-visit scheduling support at day 45
5.Re-engagement push for non-engagers at day 75
6.Care manager assignment for high-risk non-engagers
✓
New members hit established engagement milestones without member-services manually chasing each one.
Integrations
EDI 834 Enrollment Processing
Health Risk Assessment Platform
Member CRM / Engagement Platform
PCP Assignment Logic
Care Management Platform
Crisis Outreach Workflow (24/7 paging)
Industries
healthcare
See It In Action
A sample conversation with this agent
Process the overnight 834 batch from the exchange.
1,847 enrollment transactions in the batch—1,612 new enrollments, 198 changes, 37 terminations. Validating each: member demographic completeness, dependent linkage, plan eligibility, effective dates. Building member records, running HRA invitations, assigning preliminary PCPs based on geography and existing care relationships. 41 records flagged for exception handling—SEP qualifying events needing documentation, COBRA continuations missing prior employer data, and three court-ordered enrollments that need legal review. Routing those to ops; rest proceed automatically.
Maria Santos's HRA came back with active SI.
Critical flag. HRA score in the crisis tier—she answered yes to recent suicidal ideation and the depression sub-scale shows severe range. Triggering immediate workflow: paging the on-call BH care manager, suppressing automated email/SMS sequences (no chatbot conversations with someone in crisis), and pulling her contact preferences for warm phone outreach. SLA is 48 hours from HRA submission to clinician contact under our quality standards. Her record is locked from automated outreach until the care manager closes the crisis assessment. I do not handle crisis cases autonomously—this is a hard HITL gate.
How are our 60-day engagement metrics tracking?
Cohort: 4,231 members enrolled in last 90 days. 60-day engagement: 71% have completed HRA, 68% have selected PCP, 54% have scheduled or completed first visit. By acquisition source: exchange enrollees engaging at 76%, COBRA at 58%, group at 79%. SEP members are the lowest engagement cohort at 47%—pattern suggests timing/disruption is part of the issue. Drafting recommendation: shift SEP first-touch from day 14 to day 7 and add a phone outreach option. I'll route to leadership before changing the campaign.