Benefits inquiry automation that answers coverage, cost and prior approval questions from the member's own plan, every sentence cited
Coverage questions answered while the caller waits, each cited to the plan.
See one case, screen by screen ↓Software that answers members' and brokers' coverage, cost and approval questions from the plan itself. Benefits Inquiry Automation reads the member's own evidence of coverage, her deductible and out-of-pocket so far, the prior authorization list and the provider directory, and gives the representative one answer — covered or not, her cost, whether approval is needed and asked for, and whether the provider is in network — with every sentence cited.
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A member asks a plain question: is my knee MRI covered, and what will I pay? To answer it, the representative opens the evidence of coverage for her group and plan year, checks for a rider, finds her deductible and out-of-pocket met so far, looks up the allowed amount at the site, checks the prior authorization list and whether the doctor's office has asked, and confirms the imaging center is in network — while the caller waits on hold.
It is easy to read out the plan's coinsurance and stop there, to answer from last year's document or miss a group rider, to skip the prior authorization check, or to quote a directory entry nobody has verified in 90 days. Each one comes back as a surprise bill, a repeat call, a grievance or an appeal.
Estimated split of one coverage-and-cost call, in minutes, by hand and with the solution. Verifying the caller and talking it through stay with the representative.
Six specialist agents read the plan, the member's year so far, the approval list and the directory; the representative decides what is said.
Rosa Delgado, a Choice PPO 1500 member through her employer Haldane Logistics, calls at 10:44. Her orthopedist wants an MRI of her right knee. Here is the call, screen by screen, in the working solution.
Rosa was verified at 0:41 by date of birth and address. Jordan types what she asked: “Is an MRI of my knee covered, and what will I pay?” The answer comes back in four sentences: covered when her doctor orders it, about $350 at Lakeshore Imaging Center, prior approval needed and not yet asked for, and Lakeshore is in her network.
“4 sentences · 4 supported by the plan”
The question reader turns “MRI of my knee” into CPT 73721, right knee, without contrast, outpatient, plan year 2026. The plan reader cites Evidence of Coverage 2026 §4.7 page 42 and §7.2 page 61 and the SBC page 2, and notes no group rider applies. The approval and network checker finds 73721 on the prior authorization list with no request on file from Northgate Orthopedics. The citation checker reads every sentence against its passage: 0 removed.
“Jordan decides — reads it out or sends it — nothing reaches Rosa until Jordan clicks”
Claims are processed through 12 Oct with none pending. Rosa has met $1,250 of her $1,500 in-network deductible — a February lab, urgent care in March, therapy in June and July. At Lakeshore's allowed amount of $750, she pays the $250 left on her deductible, then 20% of the remaining $500: $350. The plan pays $400. Her deductible is met for the year, and her out-of-pocket goes from $1,640 to $1,990 of $5,000.
$250 deductible left + 20% × $500 = $250 + $100 = $350
Three sites within 6 miles perform 73721. Riverbend Medical Center bills it as hospital outpatient, allowed at $2,180, so Rosa's share there is $636 under the same rule. Summit Open MRI, 2.2 miles away, is not in network: up to $1,600, with the plan paying nothing until the $3,000 out-of-network deductible is met. Jordan switches the site and the answer, the arithmetic and the citations follow.
“Estimate, not a guarantee of payment · the final amount depends on the claim the provider sends”
The order came in on 8 Oct, but Northgate Orthopedics has not asked for approval. Jordan clicks “Prompt Dr. Okoye's office”. The prompt is already filled in — member, plan and group, CPT 73721, diagnosis M25.561, the in-network site, the rule and the 7-calendar-day decision clock — and goes to the office's provider portal inbox and by fax.
“The office submits the request; nothing is decided here.”
Rosa wants it in writing. The text reads the same as the answer: covered under §4.7, about $350 at Lakeshore, prior approval first, which Dr. Okoye's office requests and has now been told about, and a link that opens it in her member app with each line's plan passage. Consent to texts has been on file since 4 Jan 2026. The prior approval tile now reads “Requested from the office”.
Each numbered citation in the answer opens its source: Evidence of Coverage 2026 §4.7 Advanced imaging with the covered services and the 20% in-network coinsurance highlighted, the SBC, Rosa's accumulators, the contracted allowed amounts for 73721, the prior authorization list, the directory entry and §7.2 on prior authorization.
“this passage is what the answer says, word for word where quoted”
When Jordan clicks Save, the summary goes on Rosa's record with its citations: knee MRI covered under §4.7, about $350 at Lakeshore Imaging Center, prior approval required, office prompted 10:46, answer texted. Her record also shows the MRI 73721 prompt waiting for Northgate Orthopedics to submit, her claims this plan year and her earlier calls.
Four answers wait for Denise. Hannah Cole was told hearing aids are excluded under §6.3 — but group rider R-22 for Barrow County Schools covers $1,500 per ear every 36 months. A sleep study estimate was $28 under the paid claim after the fee schedule changed. A network answer rested on a directory entry 104 days old. A dental implant question went to a specialist because two passages disagreed. Denise accepts the corrections, coaches, and approves the new answer.
“Citation checker: the exclusion was cited, but the group's rider amending it was not.”
In the Measures preview for a 400,000-member plan: 14,820 questions answered across phone, app and broker portal in 30 days, the median time to a cited answer down to the 38-second target, 94.6% of estimates within $25 of the member's share when the claim paid, and callbacks on the same question down from 11.4% to 6.1%. 318 offices were prompted for prior approval on the call.
The same plan, seen by the five people who ask, answer and stand behind it — what their day looked like, and what it looks like now.
Six specialist agents read the plan, the member's year so far, the approval list and the directory; the representative decides what is said.
Turns the caller's words into a service, a procedure code, a setting, the member and the plan year. If two members or two services could match, it asks the representative instead of choosing.
Finds the passage that governs the service in this member's plan and group for the date of service, including riders, and quotes it with section and page. If passages disagree, it says so and stops.
Works out the member's own cost from the deductible and out-of-pocket met so far and the allowed amount at the chosen site, and shows each step of the arithmetic. When the claim pays, it compares the estimate with the member's share.
Checks the prior authorization list and whether a request is on file, and the provider directory and when the entry was last verified, flagging entries older than 90 days.
Reads every sentence of the answer against its passage, including every number, removes anything the plan does not say and flags a missing rider for the group.
Writes the call summary for the member record and the text to the member, from the answer the representative gave, with the citations.
Decides what is said; team lead reviews flagged answers. The agents propose; a named person decides.
Representatives and team leads can ask about the caller, her plan or the team's answers. Every answer is cited, and when the plan does not say, it offers to hand the question to a benefits specialist rather than guess.
Why would the hospital MRI cost almost twice as much?
Riverbend bills the MRI as a hospital outpatient service, so the contracted amount there is $2,180 against $750 at Lakeshore. Rosa's share follows the same rule at both — the $250 left on her deductible, then 20% — which is $636 at Riverbend and $350 at Lakeshore.
Has Northgate Orthopedics asked for approval yet?
No. CPT 73721 is on the Commercial prior authorization list from 1 Jul 2026, and there is no request on file for Rosa. Her plan says the ordering office asks, and the plan decides within 7 calendar days of a standard request.
Write the call summary for Rosa's record
Saved. Asked: knee MRI coverage and cost. Said: covered, about $350 at Lakeshore Imaging Center, prior approval required and not yet requested, Lakeshore in network. It is on her record under today's call.
Which answers did my team get wrong this week?
Four are waiting for Denise: a hearing-aid answer that missed the Barrow County Schools rider, a sleep-study estimate $28 under the paid claim, a network answer from a directory entry 104 days old, and a dental-after-accident question handed to a specialist. The rider one matters most — the member was told “not covered”.
13 screens from the working solution, on its sample data. Pick one to see it large.
What answers may say, how costs are worked out, and who approves the documents behind them are settings.
| Setting | Default | Choose from |
|---|---|---|
| Cite every sentence | On | A sentence without a passage is removed |
| Answer only from approved documents | On | For the plan year of the date of service |
| Member app confidence line | 85% | 75% · 85% · 90% |
| Pending claims | On | No estimate while a pending claim would change the accumulators |
| Review tolerance | $25 | $10 · $25 · $50 |
| Decision clock shown to members | Standard 7 calendar days · urgent 72 hours | Plan rule |
| Directory entries older than 90 days | On | Flag on the answer and send for verification |
| Who approves documents | Marcus Lindqvist · second: Leah Park | Benefits configuration · changed in Settings |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample health plan data (the Measures figures are preview figures for a 400,000-member plan) · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (KFF Survey of Consumer Experiences with Health Insurance, 2023 — 16% of insured adults paid more than expected; 53% of those with a problem contacted their insurer). People, plans, companies and providers named on this page are fictional — characters and sample data in the working solution.
Software that answers members' and brokers' coverage, cost and approval questions from the plan itself. Benefits Inquiry Automation reads the member's own evidence of coverage, her deductible and out-of-pocket so far, the prior authorization list and the provider directory, and gives the representative one answer — covered or not, her cost, whether approval is needed and asked for, and whether the provider is in network — with every sentence cited.
The cost estimator reads the deductible and out-of-pocket met so far, checks for pending claims, and applies the plan's cost-share to the contracted allowed amount at the site the member chooses. It shows each step — for example $250 deductible left + 20% × $500 = $350 — and labels the result an estimate, not a guarantee of payment.
No. The approval and network checker says whether prior authorization is required and whether a request is on file. If the office has not asked, the representative can send the office a pre-filled prompt; the office submits the request and the plan decides.
The plan reader searches only documents the benefits configuration analyst approved for the member's group and the plan year of the date of service, including riders. The citation checker reads every sentence against its passage, removes anything the plan does not say and flags a missing rider for the group.
Yes. Members get the same answer in their own app, and below the confidence line (85% by default) the app hands them to a person with the question already written down. Brokers get group-level answers across every plan the group offers, with no member data.
Yes. The representative decides what is said. Nothing is texted to a member, saved to the record or sent to a provider's office until the representative clicks, and the service team lead reviews flagged answers and estimates a paid claim disagreed with.
Your plan documents, eligibility and accumulators, fee schedules, the prior authorization list and requests on file, the provider directory, and the member record — with the phone team, the member app and the broker portal as channels.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your evidence of coverage, SBCs, riders, prior authorization list and a sample of member questions — and it goes live once every quality gate has passed. We will walk you through it on your own plan documents first.
Every criterion shown met or not met, with the page that proves it.
1-min demoUtilization Management AutomationNo missed 72-hour or 7-day deadline, and the yearly metrics from the same data.
1-min demoAppeals & Grievances ManagementEvery appeal decided on time, with the full file read and what is new marked.
1-min demoWe’ll run Benefits Inquiry Automation on a sample of your own plan documents and member questions.