A cited benefits investigation for the office and a plain-language letter for the patient, inside the 48-hour promise
Every patient’s coverage checked across sources and summarised for office and patient within a day.
See one case, screen by screen ↓A new prescription for a specialty drug lands at the hub, and the office has been promised an answer in 48 hours. The specialist sends the eBV, waits for the payer call, pulls the formulary and the coverage policy, and screenshots the PA criteria off the portal. Every source answers the same questions in its own words, on its own date.
The sources do not always agree, and the one that looks finished is often the oldest. An eBV that answers from June data still says tier 4 and a $50 copay after a July 1 formulary move. Step therapy and a copay accumulator can be missing from the electronic response altogether. Catching that means reading every source side by side, line by line. Then the summary for the office and the letter for the patient are written by hand, and the patient letter has to be plain enough to read and must never promise coverage.
Estimated split of working hours for one pharmacy-benefit case, by hand and with the solution.
Six specialist agents gather, read and compare the payer evidence, then write and check both summaries; a benefits specialist settles every difference and releases.
Lakeside Dermatology Associates sends an enrollment for Jordan Ellis: Veltrimab 150 mg/mL pen, plaque psoriasis, Brightwater Health PPO with Aldenway Rx as the PBM. The request lands at 16:20. Here is what happens next, screen by screen, in the working solution.
Dana opens Today and sees the hub as it stands: 10 open cases, 6 waiting for her, a median age of 15.5 h. Each case sits on the runway at its age since the request. BV-2402 is already past the promise after two payer calls dropped. BV-2417 is at 17 h, with every source in.
Needs you: “BV-2417 · J.E. · Veltrimab — All 5 sources in · run the agents.”
The hub case record with the enrollment form, the pharmacy eBV from the clearinghouse, the Aldenway Rx call transcript (ref ALW-1007-55813, 14 minutes, reviewed by a specialist), Brightwater’s July formulary and a capture of the Aldenway Rx portal’s PA criteria. Any of them opens in the viewer beside the case.
The rep, at 02:18 on the call: “As of July 1 it moved from tier 4 to tier 5.”
Dana runs the agents and watches each step as it runs. The benefit extractor reads 27 values, each linked to its source line, and notes that the eBV’s benefit data is as of Jun 15, 2026. The plan rules reader finds 4 PA criteria, 3 already met in the hub record. The source triangulator lines the three sources up value by value.
“8 values agree · 3 disagreements · 1 signal to confirm.”
Tier: the payer call and the July formulary say Tier 5, the eBV says Tier 4. Cost share: 30% after the deductible, up to $250 per fill, against a $50 copay. Step therapy: one preferred biologic first, which the eBV does not report. Each one comes with the recommended value from the newest dated source and the reason, with citations.
“Tier 5 carries 30% coinsurance after the deductible with a $250 cap per fill, read out on the call. The $50 copay is the old tier 4 amount.”
The benefits record puts the eBV response, the payer call and the formulary in three columns, with the value to use beside them. Plan status, deductible ($2,500, $410 met), out-of-pocket max ($6,800, $1,120 met), quantity limit and the specialty pharmacy (Crestline only) need nothing from her. The fourth item is a signal, not a disagreement: a copay accumulator on this plan, which the eBV does not report.
Click any value to see the line it came from.
Moderate-to-severe plaque psoriasis: L40.0 on the enrollment form. Body surface: 14% recorded Sep 29. Conventional systemic therapy: methotrexate for 16 weeks, stopped for raised liver enzymes. One preferred biologic first: not met, because there is no prior biologic. The office should request a step therapy exception with the reason.
“The PA itself is the office’s request — this summary never says it will be approved.”
Dana accepts the three recommendations and confirms the accumulator. Each choice goes on the activity record under her name. Then she presses Draft summaries. The writer fills template OS-02 v4 from the settled values only: prior authorization IS required (Aldenway Rx provider portal or fax, standard decision in 72 hours), step therapy applies, and Crestline Specialty Pharmacy is required. Then the benefit details, each with its citation, and copay support with the accumulator spelled out.
“It does not guarantee coverage or payment. Coverage and payment are decided by the payer when the claim is processed.”
The patient letter comes from approved template PL-04 v3 in short sentences: what the plan says, where the medicine comes from, what Jordan may pay, and what happens next. The checker passes it at grade 5.8 against a limit of 6. The approved no-promise sentence is there, no diagnosis is named, and the copay program is allowed because this is a commercial plan.
“This letter explains what your plan told us. It is not a promise that your plan will pay. Your plan makes the final decision.”
One screen shows what the release will do: the summary to Lakeside Dermatology Associates by portal and fax, the letter to the patient in English, and 5 tasks to Sam Patel. Dana signs, and the meaning of the signature is recorded with it.
Meaning of signature: “I reviewed the benefits values and their sources and approve this release.”
Help the office submit prior authorization through the Aldenway Rx portal, due Oct 9. A step therapy exception with Dr. Rafael Moreno, attaching the methotrexate history. Refer to Crestline Specialty Pharmacy. Enroll Jordan in the Northwind copay program, with the accumulator in mind. Call Jordan this week. A reverification reminder is set for Dec 1, 2026, because the plan renews on Jan 1.
“Accumulator applies — plan the year with the patient.”
The same case, seen by the four people on the hub team who carry it: what their day looked like, and what it looks like now.
Six specialist agents gather, read and compare the payer evidence, then write and check both summaries; a benefits specialist settles every difference and releases.
Brings every piece of payer evidence into the case: eBV responses, call transcripts, plan documents, portal captures and the hub record. It also says what is still missing.
Reads about 27 benefit values from each source: status, tier, cost share, deductible and out-of-pocket with amounts met, PA, step therapy, quantity limit or site of care, specialty pharmacy, accumulator wording. Each value keeps its source line.
Turns formulary footnotes, coverage policies and portal criteria into a PA and step-therapy checklist. It then checks each criterion against what the hub record already documents.
Compares the eBV, the payer call and the plan document value by value. It explains each disagreement (stale eBV data, a mid-year update, a different benefit) and recommends the newest dated source.
Drafts the office benefits summary and the plain-language patient letter, in English or Spanish, from the approved templates and the settled values only.
Checks every letter and summary before a person can release it: template version, reading level, the no-promise sentence, minimum necessary health information and the government-plan rule.
Settles and confirms. The agents propose; a named person decides.
Anyone on the hub team can ask in plain words, or tell it what to change. Every answer shows the line it came from.
What does Jordan’s plan need before the first fill?
Four things. Prior authorization is required; the hub record already meets 3 of 4 criteria: the diagnosis, 14% body surface and 16 weeks of methotrexate. Step therapy: one preferred biologic first, and Jordan has had none, so the office needs an exception with the reason. Crestline Specialty Pharmacy only. Cost: tier 5 since Jul 1, 30% after the deductible, up to $250 a fill. The eBV’s $50 copay is from Jun 15 data, and copay help won’t count toward the deductible.
Which cases have a copay accumulator or maximizer?
3 cases this week: BV-2414 on Cobalt Ridge HMO (maximizer), BV-2415 on Brightwater Health PPO (accumulator) and BV-2408 on Saltmarsh Employer Plan (maximizer). BV-2417 will join them, because the call says the plan has a copay adjustment program. Accumulators stop copay help from counting toward the deductible. Maximizers spread it across the year and need the plan’s own enrollment.
Re-call the payer whenever the eBV and the call disagree on cost
Done. New rule: when the eBV and the payer call disagree on tier or cost share, the AI caller calls the payer back and asks for the effective date before the case reaches you. Over the last 30 days this would have caught 41 cases early, most of them mid-year tier moves like Brightwater’s Jul 1 update. The rule is in Settings and on the audit trail.
Write Jordan’s letter in Spanish
Set. Jordan’s letter will be written from the approved Spanish edition of PL-04 v3. The writer drafts it as soon as you settle the open items on BV-2417: the tier and cost, step therapy and the accumulator.
13 screens from the working solution, on its sample data. Pick one to see it large.
The promise to offices, the checks and the letters are settings. New rules are described in a sentence and become a check once approved.
| Setting | Default | Choose from |
|---|---|---|
| Turnaround promise to offices | 48 hours | Set in hours · amber at three quarters, red past it |
| Recommend the newest dated source | On | On · Off |
| Second check for Medicare and Medicaid cases | Omar Haddad | Omar Haddad · Lena Ortiz |
| No promise of coverage | On | A standing rule: every letter carries the approved no-promise sentence |
| Call reference on every summary | On | A standing rule: an office summary needs the payer call reference number |
| Highest reading level for patient letters | Grade 6 | Set by school grade · letters above it are held |
| Letter template | PL-04 v3 · approved Sep 2 | PL-04 v3 (approved Sep 2) · PL-04 v2 (retired Sep 2) |
| Offer Spanish letters | On | On · Off · uses the language on the enrollment form |
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 hub data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (benefit-verification case studies, vendor-reported, 2024–2025). People, companies and products named on this page are fictional — characters and sample data in the working solution.
A benefits investigation, or benefit verification, finds out what a patient’s plan will cover for a prescribed drug and what the patient will pay. That includes tier, cost share, deductible and out-of-pocket amounts, prior authorization, step therapy, the specialty pharmacy and any copay accumulator. The Benefits Investigation Summary Builder gathers the evidence, cites every value to its source and drafts a summary for the office and a letter for the patient.
The source triangulator puts the eBV, the payer call and the plan document side by side, value by value. When they disagree it explains why, for example eBV data dated before a mid-year formulary update, and recommends the newest dated source. A benefits specialist settles every disagreement before anything is drafted.
Yes. Accumulator and maximizer wording on the call or in the plan document is raised as a signal for the specialist to confirm, even when the eBV does not report it. Once confirmed, it goes into the office summary, the patient letter and the case manager’s tasks.
No. Every letter carries the approved no-promise sentence word for word, is written from an approved template, and is held if it reads above the set school grade. For Medicare and Medicaid plans it never mentions the copay program. The compliance checker blocks release on any failed check.
Never. The plan rules reader checks each PA and step-therapy criterion against the hub record and marks it met or not met with the passage. The summary tells the office what to submit and where. The decision stays with the payer.
Yes. The agents gather, read, compare and draft. A benefits specialist settles every disagreement, confirms every signal and releases with an electronic signature. Government-plan cases get a second check from a named person, and every step is on the case’s activity record.
Yes. When Spanish letters are on, the writer uses the language on the enrollment form and the approved Spanish edition of the letter template, with the same facts and the same checks.
The Agentic Solution Engine builds and deploys it from your requirements and documents: your summary and letter templates, your plan library and a sample of past cases. It goes live once every quality gate has passed. We will walk you through it on your own cases first.
Every patient-programme call, email, chat and note is read in full, and each side effect reaches safety inside the 24-hour window.
1-min filmEnrollment IntakeEvery faxed or portal enrollment form becomes a cited patient-support case in minutes, the same day it arrives.
1-min filmPrior AuthorizationEvery request reaches the payer with each criterion proven from the chart, so patients start treatment in days.
1-min filmWe’ll run the Benefits Investigation Summary Builder on a sample of your own eBV responses and payer calls.