PAP eligibility review with every rule cited, most applications decided within a day
Every free-medicine application is checked against every rule, each figure cited, and most are decided within a day.
See one case, screen by screen ↓A patient assistance application rarely arrives as one clean document. It comes by fax, portal or mail: the application, two pay stubs or a tax return, an insurer’s letter, a prescription, three separate signatures. Before anyone can decide, a reviewer has to sort the pages, annualise every income figure, work out the household size, find the coverage path and confirm the patient, the prescriber and the privacy authorisation are all signed.
The hard part is not the arithmetic — it is the cases where the papers disagree. An application lists four people; last year’s tax return shows three, because a baby was born after the tax year. At that household size the patient is either well under the limit or over it. And every answer has to be the one the next reviewer would give for the same facts, with the prescriber and the office never part of the decision.
Estimated split for a typical new application against the 4.5-day standard, by hand and with the solution.
Specialist agents read the packet, work out income, check coverage and signatures and apply every rule; a reviewer decides and signs, then the letter goes out.
Ana Ruiz, 41, of Phoenix, applies for free Veltrimab after her insurer upheld its denial on appeal. Her 11-page packet arrives by fax. Here is what happens next, screen by screen, in the working solution.
Sam opens the solution to 20 open applications across Veltrimab, Corventa and Talmirex: 3 need him, 7 are clear to approve, 4 are recommended for denial and 5 are waiting on documents. The eligibility map plots each one by household size against the 400% programme limit — and one dot sits on both sides of the line: Ana Ruiz, 359% if her household is 4, 433% if it is 3.
Needs you · 3 — “a conflict to resolve or a second signature.”
Maria Santos’s Talmirex application came in by fax at 08:42. Sam presses “Read the 08:42 fax”: the Packet Reader splits 8 pages into 4 documents and masks the tax IDs, the Income Calculator annualises her weekly pay to $53,040, the Coverage Checker records her as uninsured, as she attested, and the signature check finds 3 of 3 signatures and a valid NPI.
“PAP-10426 read in 41 s — clear to approve at 194% of the guideline.”
PAP-10418 opens with the packet on the left — application, prescription, two pay stubs, the 2025 Form 1040, the appeal decision letter — each with its classification score. The recommendation is plain: “Needs you — the household size decides the outcome.” Everything else checks out. It is 0.9 of 4.5 business days in.
Page 2 of the application lists four people: Ana, her husband Marco, their daughter Sofia, 9, and Leo, born March 2026. Page 8, the 2025 tax return, shows married filing jointly with one dependent — three people. Sam clicks the citation and the return opens on the right with the dependents line highlighted.
“Leo was born in March 2026, after the 2025 tax year, so the return could not list him.”
Ana’s pay stubs from Copperline Logistics, dated Sep 11 and Sep 25, show $3,780 bi-weekly — × 26 is $98,280. Marco’s 2025 Schedule C net profit adds $20,120: $118,400 from two sources. Sam flips the household from 4 to 3 and watches the share move from 359% to 433% of the guideline.
“Arithmetic recomputed, never rounded early.”
Lives in the U.S. — Phoenix, AZ, the same address as the pay stub. Prescribed for an approved use — Veltrimab for moderate-to-severe ulcerative colitis. Dr. Ravi Menon’s NPI, Crestline Health’s denial upheld on appeal on Sep 24, all three signatures: met. The Medicare Part D rule does not apply. Only household size and the income limit are open — 11 of 13, rules version 2026.4.
The Rule Checker never considers the prescriber, the office or the volume of prescriptions.
The programme counts the people living in the home today, as attested on the application, and uses the tax return for income only. Sam chooses “Count 4 — Leo was born after the tax year”. The recommendation turns to “Recommend approve — all 13 rules met”, and his count and reason go on the audit trail.
Veltrimab, free for 12 months, Oct 7, 2026 to Oct 6, 2027. Shipped by Clearwater Free Goods Pharmacy, with the referral sent on signing. Basis: 4 people, 359% of the guideline, 13 of 13 rules met. No second signer is needed — this is not a denial and not a Medicare Part D case. The approval letter is shown in full before he presses “Sign and send”.
Approved by Sam Patel at 09:12. The approval letter, written from the approved template, tells Ana the pharmacy will call within one business day, that there is no cost and no insurance to use, and that Dr. Menon has been told. The referral is made and the re-enrolment reminder is set for Aug 22, 2027.
Highlighted values come from the decision record. Income line items never appear in letters.
The same programme, seen by the four people who run it — what their week looked like, and what it looks like now.
Specialist agents read the packet, work out income, check coverage and signatures and apply every rule; a reviewer decides and signs, then the letter goes out.
Splits each faxed, uploaded or mailed packet into pages and labels every document: application, pay stub, tax return, benefit letter, insurance letter, Medicare letter, prescription.
Extracts every income figure, annualises pay stubs and benefit letters, adds every household source and works out the share of the poverty guideline — with the arithmetic shown.
Decides the coverage path — uninsured, denied after appeal, or Medicare Part D — and checks the letter that proves it.
Confirms the patient and prescriber signed and dated, the privacy authorisation is signed, the prescriber NPI is valid and the address is in the U.S.
Applies the 13 programme rules to every application the same way and proposes approve, request more or deny — each with its citations.
Writes approval, denial, missing-document and re-enrolment letters from approved templates, in plain language, and refers approved patients to the free-goods pharmacy.
Decides and signs every application. The agents propose; a named person decides.
Reviewers can ask about any application, rule or letter — or tell it what to change. Every answer cites the page or the rule it rests on.
Why does Ana Ruiz’s application need me?
PAP-10418 meets 11 of 13 rules. The two open ones — household size and the income limit — turn on one question: the application lists 4 people, the 2025 tax return shows 3, because her son Leo was born in March 2026. With 4 people, $118,400 is 359% of the guideline; with 3 it is 433%. The household rule counts the people living in the home today, so I recommend counting 4 — that makes her eligible.
How do you handle Medicare Part D patients?
Free medicine is given outside the Part D benefit, the plan is told so it never counts toward out-of-pocket costs, and the patient must have spent at least 3% of household income on prescriptions this year. A second person always signs. Walter Brooks spent $1,960 on an income of $31,800 — 6.2%, so he qualifies. George Lambert spent 1.7%, so the recommendation is a denial with a note on when to re-apply.
How do you annualise pay stubs?
The same way every time: weekly × 52, bi-weekly × 26, semi-monthly × 24, monthly × 12. The most recent proof wins, and it must be dated within 90 days. Out-of-date proof is requested again — it is never a reason to deny.
Can we prove decisions are consistent?
Yes. Every night the consistency check compares decisions with the same facts: in the last 30 days, 1,186 decisions in 5 fact patterns, 0 that differ. Nine reviewer overrides each carry a written reason. The prescriber, office and prescription volume are never inputs.
13 screens from the working solution, on its sample data. Pick one to see it large.
Programme rules apply to every application the same way. Changes are versioned and audited.
| Setting | Default | Choose from |
|---|---|---|
| Household income limit | 400% of the poverty guideline | 300 · 400 · 500 · 600% |
| Medicare Part D: out-of-pocket spend | 3% of household income | 2 · 3 · 5% |
| Income proof must be dated within | 90 days | 60 · 90 · 120 days |
| Enrolment length | 12 months | 6 · 12 months |
| Denials need a second signer | On | On · Off |
| Medicare Part D approvals need a second signer | On | On · Off |
| Missing-document requests go to | Whoever can fix it | Whoever can fix it · Always the office |
| Follow up an unanswered request after | 3 days | 2 · 3 · 5 days |
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 programme data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (URAC industry standard for free-goods new-patient turnaround — 4.5 business days; HHS-OIG guidance on patient assistance programmes — rules applied consistently). People named on this page are characters in the working solution; Northwind Cares, Veltrimab, Corventa and Talmirex are its sample programme and medicines.
Software that takes a free-medicine application from the packet that arrives to a signed decision and the letter to the patient. The Patient Assistance Application Adjudicator adds agents that read the packet, work out household income against the poverty guideline, check the coverage path and signatures, and apply every programme rule with a citation — so a reviewer decides on the evidence, not the paperwork.
The Income Calculator extracts every income figure, annualises it the same way every time (weekly × 52, bi-weekly × 26, semi-monthly × 24, monthly × 12), adds every household source and compares the total with the HHS poverty guideline for the household size. The arithmetic is shown, and every figure cites the page it came from.
The application goes to a reviewer with both pages side by side and the share of the guideline at each household size. The programme counts the people living in the home today, as attested on the application, and uses the tax return for income only. The reviewer records the count and the reason on the audit trail.
Yes. The Coverage Checker reads the plan letter and the out-of-pocket statement and checks spend against the programme’s share of income. Free medicine is given outside the Part D benefit, the plan is told, and a second person always signs.
No. Agents recommend; a person signs every approval and denial, and that setting cannot be turned off. Denials and Medicare Part D approvals need a second signer, and a missing signature always becomes a request, never a denial.
The Rule Checker applies the same 13 rules, in the same version, to every application. A consistency check compares decisions with the same facts every night, and the prescriber, the office and prescription volume are never inputs to a decision.
Yes. Every night it finds enrolments ending in the next 45 days, pre-fills the form from last year and drafts reminders for a person to send. Patients who do not reply are flagged as at risk of a gap, with a call task.
The Agentic Solution Engine builds and deploys it from your requirements — your programme rules, application forms, letter templates and a sample of past packets — and it goes live once every quality gate has passed. We will walk you through it on your own applications 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 Patient Assistance on a sample of your own past application packets.