12 Custom AI Agents for Health Plans

At volumes never before possible, achieve outbound engagement that human-staffed call centers and coordinators just can’t do alone.

24/7 Outreach: across voice, SMS, and email. Connect to your members when they’re actually available to talk. Greet them in their own language. Use their preferred communication channel.

Scale your outreach without adding headcount:

• HRA and assessment outreach
• Preventive services and medical screening reminders
• HEDIS and Star gap closures
• Post-discharge follow-ups
• Chronic condition check-ins
• Medication therapy management

Seasonal surge bottlenecks won’t affect how you hit those SNP and HRA deadlines anymore. Raise your Star ratings by closing screening and adherence gaps, and reduce readmissions with timely post-discharge contact.

HUMAN-IN-THE-LOOP. Every conversation is logged, compliant, and escalated to a human when needed — at roughly 75% lower cost than traditional outreach. It can also acknowledge case receipt and request missing documents across CM, UM, and A&G.

Resolve the bulk of your call center volume, with zero hold time — whether at 2 a.m. or during open-enrollment surges.

Inbound member and provider calls answered 24/7:

• eligibility and benefits questions
• claim status
• prior authorization status
• appeal and grievance status

The caller is HIPAA-authenticated, served in their language, and answered from live core-system data.

Operations leaders: Reduce overhead costs and maximize your team’s efficiency by automating routine, high-volume inquiries. Now your call center can easily manage sudden call spikes without the cost of hiring temporary staff. Free up your human agents to handle the complicated or sensitive issues like complex claim denials or appeals. When human empathy is made available, instead of being burdened by routines easily answered by conversational AI, member experience is more positive; they feel cared for, and you benefit.

Member experience leaders: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey asks your members, “In the last 6 months, how often did customer service at your health plan give you the information or help you needed?” They can answer with praise because they get their answers immediately.

The Omni-Channel Notification Agent automates the regulated communications that plans must send across Care Management (CM), Utilization Management (UM), Appeals and Grievances (A&G), and Claims.

Automate regulated communications in compliance — mail, SMS, email, and AI voice:

• determination letters
• acknowledgments
• status updates
• resolution notices

Each communication is triggered by a case event, generated from an approved template, delivered in the member’s language, and timestamped for compliance.

Guarantee adverse determinations go out:

1. Within the regulatory window
2. Expedited acknowledgments happen in hours
3. Without hand-generating correspondence by your staff

Plans see roughly 75% time savings on notification workflows. Now you can eliminate the missed letters that plague audits.

Imagine what’s possible in under 2 minutes. The Intake Agent turns a request — fax, letter, phone call, web portal, or email — into a structured, classified UM, A&G, or Claims case. In no time at all, you have a structured, classified UM, A&G, and Claims case.

The Intake Agent automates 95% of your intake process:

• classifies request type
• AOR documentation verified
• expedited requests flagged
• each case routed to the right queue

Clear the intake backlog that’s putting you at risk. Before a case even opens, you’ll catch expedited appeals on arrival — no more days later in a mailroom queue. Circumvent intake staff redeployment by automating upon receipt.

The clock starts at receipt, making automated intake a plan’s single highest-impact step toward timeliness. Trigger an automated workflow from receipt, and the clock stops being the enemy; it becomes the reward.

Continuous stratification of your claims, EMR, and HRA data. With the Identification & Stratification agent, you can assign dynamic risk tiers across your member population. You’ll no longer need to rely on static, annual stratification.

Access current real-time data, anytime.

When applying CMS-HCC or other models, the Identification & Stratification agent flags rising-risk members. Now you can flow resources to those who need them by getting a timely picture of members whose trajectory has changed since the last assessment.

Use it to:

• prioritize caseloads by current clinical reality
• identify disease-management and complex-case members earlier
• support accurate risk adjustment
• show regulators a systematic, current methodology

Plans using dynamic stratification intervene months earlier than annual snapshots allow.

Find the clinical story with complete, real-time data. The Clinical Summary Agent builds clinical summaries from every available source:

• Claims
• UM history
• care management
• call notes
• medical records

Clinical summaries are tailored to whoever needs them:

• care managers preparing outreach
• medical directors reviewing UM cases
• A&G coordinators assembling appeal files

Summaries are CMS Interoperability compliant and cut preparation time by as much as 80%. Eliminate hours of clinical staff rebuilding member histories from fragmented systems. Now you can give every reviewer a consistent evidence picture, and accelerate any workflow that starts with “What’s the clinical story here?”

The ICP Agent auto-generates federally mandated Individualized Care Plans:

• goals
• barriers
• interventions
• milestones
• actions

Using member assessment data — claims, clinical history, and risk profile — ICPs have never been easier or faster to generate. What takes a care manager 60–90 minutes can be completed in under 5 minutes, with the care manager reviewing and personalizing, instead of starting from a blank template.

For Special Needs Plans, it’s the difference between ICP timeliness compliance and CMS findings: every enrolled member gets a compliant plan within required timeframes, regardless of volume. For care management leaders, it converts documentation hours back into member-facing time.

Catch deterioration before it becomes an ER visit. Turn any remote monitoring device into real-time care workflows:

• blood pressure cuffs
• glucometers
• scales
• pulse oximeters

Monitoring between touchpoints allows context-based alerts when readings trend toward concerning conditions. The agent feeds data directly into care workflows and can open new revenue through CPT 99453–99458 billing.

Use the RPM agent to monitor:

• congestive heart failure (CHF)
• HF
• diabetes
• hypertension
• COPD

The RPM agent workflow monitors populations continuously rather than episodically, so you can catch deterioration before it becomes an ER visit or readmission. It allows you to build an RPM program that generates reimbursement rather than pure cost. For delegated or value-based arrangements, it provides the between-visit visibility that makes total-cost-of-care management real.

Conversational Analytics lets anyone — from executives to care management supervisors — ask questions of data at any time and get immediate answers.

• No more report queues
• No monthly-refresh wait
• Eliminate analyst backlogs

Ask your data questions about population health, HEDIS and Star performance, and operational metrics in plain English. Which measures are trending below cut points? What’s our expedited appeal volume this quarter versus last? Which counties have the lowest HRA completion?

The timelier the data, the quicker you can respond to trend lines. Turn quality and operations reviews into live working sessions. Give supervisors timely data visibility in seconds, not weeks — reducing analytical work by more than 60%.

Do your clinical reviewers have complete, criteria-mapped case files? Or are they working through a stack of faxed records?

With the UM Evidence & Recommendation agent, the clinical evidence is aggregated for each prior authorization; it applies InterQual/MCG criteria and your GoldCarding rules, and generates a determination recommendation with a confidence score.

Accelerate clean approvals:

• Give members and providers answers in hours.
• Apply consistent criteria across every reviewer and shift.
• Focus physician time only on genuine borderline cases.
• Produce documentation that stands up to CMS scrutiny and provider disputes.

Plans see roughly 70% savings on evidence assembly and review prep.

The A&G Decision Agent assembles the whole evidence picture:

• clinical summaries
• prior authorization history
• claims
• care management records
• medical records
• drafts an evidence-based decision recommendation

With the A&G Decision Agent, nothing is decided on a partial file. Every recommendation traces to its supporting evidence.

• resolve cases well within 30-day and 72-hour timelines
• reduce IRE-level overturns by getting first-level decisions right
• ensure that when a regulator pulls a file, the evidence trail is complete and organized

Reviewers report roughly 70% time savings.

The Claims Pend Resolution agent is fast. When evidence examiners manually search across 8+ systems, manually assembling results is time-consuming.

Turn a 25–30-minute task into 5 minutes by automating the hunt for evidence:

• eligibility
• authorization
• provider contract
• clinical documentation
• claims history

Resolve pended claims fast with compliance-ready documentation on every resolution.

• Work down your pend inventories.
• Avoid prompt-pay risk and provider abrasion.
• Absorb volume growth without hiring examiners.
• Standardize resolution so identical claims get identical treatment.

For plans facing prompt-pay penalties or payment-delay friction, the Claims Pend agent attacks the root cause directly.