Substrate ARC: Eligibility

Most denials start before the claim is ever sent.

Prevent denials at the source by verifying coverage before the visit, and re-verifying the claims that slip through. It works autonomously, escalating only true exceptions.

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How Substrate ARC works

Autonomous verification of coverage, benefits and coordination of benefits before the visit, so eligibility errors never become denials.

Every channel, one agent combines EDI 270/271 eligibility, payer portals and direct APIs into one verified answer across thousands of payers.

Ends calls to payers
Most billing teams spend hours on the phone with payers. Substrate uses EDI, APIs, and logs into portals like a biller would, to get the richest data possible.

Resolves payer complexity
‍Payer name variations, NPI routing, sub-plan quirks - the agent resolves all of it automatically. You send us the claim, it figures out where to go and how to get a response.

Gets smarter with every claim
When a combination of inputs and routes works, the agent remembers it. Future claims start with proven strategies instead of guessing. This compounds across millions of claims.

Pick Four

You don't have to pick two.

Most vendors make you pick two of these. With Substrate, you get all four.

More clean claims that pay on first submission.

Faster

Coverage and benefits verified in seconds, not on hold.

Lower

Fewer eligibility denials and lower cost to collect.

Easy

Runs inside your PM and EMR. No portal logins, no exports.

Increase

First-pass eligibility success

Fewer

Front end and registration denials

Across

3,500+

payers via EDI, API, and portal

Within

Seconds

to verify coverage and benefits

How the eligibility agent works. From a scheduled visit to a verified, clean claim.

Verifies coverage pre-visit

Confirms plan, effective dates, covered CPT codes, and coordination of benefits, and flags carve-out plans before the claim goes out.

Validates demographics and benefits

Checks patient demographics against payer records and surfaces deductible, copay, coinsurance, and out-of-pocket max.

Flags prior-auth and referrals

Flags procedures that need prior authorization or a PCP referral before the visit.

Re-verifies denied claims

Re-verifies coverage on eligibility-denied claims as of the date of service, corrects mismatches, and resubmits.

Tracks to adjudication

Monitors each claim through adjudication.

AI Agents that are designed & built for the way your claim status works.

Multi-route infrastructure uses EDI, clearinghouses, direct APIs and browser-based portal agents with automatic fallback for weak data.

Intelligent browser agents are onboarded similarly to a human biller with credentials then navigating payer sites to find the claim.

Custom queue mapping connects payer denial codes and descriptions to your internal systems, notes and next actions based on your rules.

Payer routing lets the agent build profiles of each payer over time including required inputs, best routes, hours of operation and downtime patterns.

Deep integrations connect statuses, notes and next actions push directly into your PM or system of record with no manual data entry.

Immediate results with only eight data fields, no migration or engineering work on your end and get results back to your system instantly.

Need tailored automation?

Our AI engineers embed with your team to build & automate pipelines

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Security first, from the ground-up

End-to-end encryption protects sensitive data in transit and at rest, ensuring complete confidentiality.

Zero-trust architecture verifies every request, reducing attack surfaces and preventing unauthorized access.

Regular security audits and compliance checks keep our infrastructure resilient against evolving threats.

Granular access controls allow precise permission management, securing data at every level of the system.

Trust & Security →

HIPAA

SOC2

See Substrate ARC run your eligibility.

Book a 30-minute demo. We'll show you pre-visit verification and denial recovery on your payers.

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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.

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