The agent turns dense payer policies into enforceable criteria. Then it runs your records against them automatically, constantly comparing and evaluating
A claim arrives for processing and the agent pulls patient demographics, subscriber info and payer details from your system of record.
Eligibility Lookup
The agent queries eligibility across EDI, direct APIs and payer portals. It checks primary, secondary and tertiary coverage in parallel.
Coverage Validation
Active coverage is confirmed and plan details, benefit levels, COB order and effective dates are extracted and normalized.
Claim Routing
Validated eligibility data is used to route the claim to the correct payer and submission path for claim status and follow-up.
Denial Detection
If a claim is denied for eligibility reasons, the agent identifies it and pulls the current eligibility documentation needed to appeal.
Resolution
Eligibility documentation is packaged and fed into the Appeals Agent for submission — or COB is updated and the claim is resubmitted to the correct payer.
Eligibility data that powers the revenue cycle
Route claims intelligently using real-time eligibility data to determine the correct payer, plan and submission path prior to claim status.
Primary & secondary payer identification
Active coverage confirmation
Plan-level benefit details
Fill coordination of benefits by pulling eligibility across multiple payers to resolve COB gaps & ensure claims are billed to the right plan in the right order.
Multi-payer eligibility checks
COB order determination
COB updates to your PM
Resolve eligibility denials by retrieving & submitting current eligibility documentation as part of an appeal without manual portal lookups or phone calls.
Eligibility-based denial identification
Documentation retrieval for appeals
Connects directly with Appeals Agent
FAQ
What does the Eligibility Agent do?
It autonomously verifies patient eligibility for claim routing, coordination of benefits and resolving eligibility-based denials.
How does it check eligibility?
Through a combination of EDI transactions, direct payer APIs and browser-based portal agents — the same infrastructure that powers our claim status agent.
Does it handle coordination of benefits?
Yes. It checks eligibility across multiple payers, determines COB order and updates your PM with the correct billing sequence.
Can it resolve eligibility denials?
Yes. When a claim is denied for eligibility, the agent retrieves current eligibility documentation and feeds it into the Appeals Agent for resubmission.
How fast does it run?
Eligibility checks run in real time as claims enter the system. Most results are returned within seconds.
Does it integrate with my PM?
Yes. Results are pushed directly into your practice management system. No exports, no manual data entry.
