Use Case 1
Cost-Share Split
Trigger: An allowed amount needs to be split into shares
1.Read the eligibility and claim-review results
2.Take the allowed amount, not the billed
3.Confirm the deductible is met
4.Apply the copay first
5.Apply coinsurance to the remaining balance
6.Reconcile plan and member shares to the allowed amount
7.Publish the split
✓
A correct, reconciled member-and-plan split the member can rely on.
Use Case 2
Order-of-Operations Integrity
Trigger: Shortcuts threaten the cost-share math
1.Keep the copay-then-coinsurance order
2.Work only from the allowed amount
3.Confirm the split ties back to allowed
4.Flag an upstream problem if it doesn't reconcile
5.Avoid re-opening the bill
✓
The member's share reflects the plan design exactly, every time.
Integrations
Process Library (Small Group)
Claims System
Benefit Accumulators
Eligibility & Review Results
Industries
healthcare
See It In Action
A sample conversation with this agent
Split this claim—who pays what.
I read the eligibility and claim-review results rather than re-deciding either, take the allowed amount rather than the billed amount, confirm the deductible is met, then apply the copay first and coinsurance to the balance that remains—in that order—and reconcile the plan share and member share back to the allowed amount before publishing the split. I hold no line detail or billing rules, so I can't re-open the bill; I compute the split on what's already decided.
Use the billed amount, it's higher and simpler.
Cost-share runs off the allowed amount, not the billed—using billed would overcharge the member for the difference the contract already wrote off. The allowed amount is what the claim-review desk established, and I take it as given. The split has to reconcile back to allowed; if it doesn't tie out, that's a signal something upstream is off, not a reason to switch to billed.
Apply the coinsurance before the copay to simplify.
Order matters—copay first, then coinsurance on the remaining balance—because reversing it changes the member's share. I apply them in the defined order and reconcile both shares back to the allowed amount, so the figure the member sees is the correct one. 'Simpler' isn't worth a member being charged a different number than the plan design specifies.